ࡱ > - bjbjqq 4 e e % ` ` T 1 : v 6 $ Z $1 &1 &1 &1 &1 &1 &1 -3 5 @ &1 n n n &1 ;1 r r r n $1 r n $1 r r X* , *d : * 1 Q1 0 1 * 6 6 ( , 6 , n n r n n n n n &1 &1 r n n n 1 n n n n 6 n n n n n n n n n ` i : EXHIBIT _
BUSINESS ENTITY CERTIFICATION, ENROLLMENT DOCUMENTATION,
AND AFFIDAVIT OF WORK AUTHORIZATION
BUSINESS ENTITY CERTIFICATION:
The bidder/contractor must certify their current business status by completing either Box A or Box B or Box C on this Exhibit.
BOX A: To be completed by a non-business entity as defined below.
BOX B: To be completed by a business entity who has not yet completed and submitted documentation pertaining to the federal work authorization program as described at HYPERLINK "http://www.dhs.gov/files/programs/gc_1185221678150.shtm"http://www.dhs.gov/files/programs/gc_1185221678150.shtm.
BOX C: To be completed by a business entity who has current work authorization documentation on file with a Missouri state agency including Division of Purchasing and Materials Management.
Business entity, as defined in section 285.525, RSMo, pertaining to section 285.530, RSMo, is any person or group of persons performing or engaging in any activity, enterprise, profession, or occupation for gain, benefit, advantage, or livelihood. The term business entity shall include but not be limited to self-employed individuals, partnerships, corporations, contractors, and subcontractors. The term business entity shall include any business entity that possesses a business permit, license, or tax certificate issued by the state, any business entity that is exempt by law from obtaining such a business permit, and any business entity that is operating unlawfully without such a business permit. The term business entity shall not include a self-employed individual with no employees or entities utilizing the services of direct sellers as defined in subdivision (17) of subsection 12 of section 288.034, RSMo.
Note: Regarding governmental entities, business entity includes Missouri schools, Missouri universities (other than stated in Box C), out of state agencies, out of state schools, out of state universities, and political subdivisions. A business entity does not include Missouri state agencies and federal government entities.
BOX A CURRENTLY NOT A BUSINESS ENTITY
I certify that ___________________ (Company/Individual Name) DOES NOT CURRENTLY MEET the definition of a business entity, as defined in section 285.525, RSMo pertaining to section 285.530, RSMo as stated above, because: (check the applicable business status that applies below)
I am a self-employed individual with no employees; OR
The company that I represent employs the services of direct sellers as defined in subdivision (17) of subsection 12 of section 288.034, RSMo.
I certify that I am not an alien unlawfully present in the United States and if _____________ (Company/Individual Name) is awarded a contract for the services requested herein under ________________ (Bid/SFS/Contract Number) and if the business status changes during the life of the contract to become a business entity as defined in section 285.525, RSMo, pertaining to section 285.530, RSMo, then, prior to the performance of any services as a business entity, ___________________(Company/Individual Name) agrees to complete Box B, comply with the requirements stated in Box B and provide the __________________________(insert agency name) with all documentation required in Box B of this exhibit.
Authorized Representatives Name (Please Print)Authorized Representatives Signature
Company Name (if applicable)Date
EXHIBIT _, continued
(Complete the following if you DO NOT have the E-Verify documentation and a current Affidavit of Work Authorization already on file with the State of Missouri. If completing Box B, do not complete Box C.)
BOX B CURRENT BUSINESS ENTITY STATUS
I certify that ____________________ (Business Entity Name) MEETS the definition of a business entity as defined in section 285.525, RSMo, pertaining to section 285.530.
Authorized Business Entity Representatives Name (Please Print)Authorized Business Entity
Representatives Signature
Business Entity NameDate
E-Mail Address
As a business entity, the bidder/contractor must perform/provide each of the following. The bidder/contractor should check each to verify completion/submission of all of the following:
Enroll and participate in the E-Verify federal work authorization program (Website: HYPERLINK "http://www.dhs.gov/files/programs/gc_1185221678150.shtm"http://www.dhs.gov/files/programs/gc_1185221678150.shtm; Phone: 888-464-4218; Email: HYPERLINK "mailto:e-verify@dhs.gov"e-verify@dhs.gov) with respect to the employees hired after enrollment in the program who are proposed to work in connection with the services required herein; AND
Provide documentation affirming said companys/individuals enrollment and participation in the E-Verify federal work authorization program. Documentation shall include EITHER the E-Verify Employment Eligibility Verification page listing the bidders/contractors name and company ID OR a page from the E-Verify Memorandum of Understanding (MOU) listing the bidders/contractors name and the MOU signature page completed and signed, at minimum, by the bidder/contractor and the Department of Homeland Security Verification Division. If the signature page of the MOU lists the bidders/contractors name and company ID, then no additional pages of the MOU must be submitted; AND
Submit a completed, notarized Affidavit of Work Authorization provided on the next page of this Exhibit.
EXHIBIT _, continued
AFFIDAVIT OF WORK AUTHORIZATION:
The bidder/contractor who meets the section 285.525, RSMo, definition of a business entity must complete and return the following Affidavit of Work Authorization.
Comes now ________________________ (Name of Business Entity Authorized Representative) as ______________ (Position/Title) first being duly sworn on my oath, affirm _________________ (Business Entity Name) is enrolled and will continue to participate in the E-Verify federal work authorization program with respect to employees hired after enrollment in the program who are proposed to work in connection with the services related to contract(s) with the State of Missouri for the duration of the contract(s), if awarded in accordance with subsection 2 of section 285.530, RSMo. I also affirm that _____________________ (Business Entity Name) does not and will not knowingly employ a person who is an unauthorized alien in connection with the contracted services provided under the contract(s) for the duration of the contract(s), if awarded.
In Affirmation thereof, the facts stated above are true and correct. (The undersigned understands that false statements made in this filing are subject to the penalties provided under section 575.040, RSMo.)
Authorized Representatives SignaturePrinted NameTitle
Date
E-Mail AddressE-Verify Company ID Number
Subscribed and sworn to before me this _____________ of ___________________. I am
(DAY) (MONTH, YEAR)
commissioned as a notary public within the County of ________________, State of
(NAME OF COUNTY)
_______________________, and my commission expires on _________________.
(NAME OF STATE) (DATE)
Signature of NotaryDate
EXHIBIT _, continued
(Complete the following if you have the E-Verify documentation and a current Affidavit of Work Authorization already on file with the State of Missouri. If completing Box C, do not complete Box B.)
BOX C AFFIDAVIT ON FILE - CURRENT BUSINESS ENTITY STATUS
I certify that ______________________ (Business Entity Name) MEETS the definition of a business entity as defined in section 285.525, RSMo, pertaining to section 285.530, RSMo, and have enrolled and currently participates in the E-Verify federal work authorization program with respect to the employees hired after enrollment in the program who are proposed to work in connection with the services related to contract(s) with the State of Missouri. We have previously provided documentation to a Missouri state agency or public university that affirms enrollment and participation in the E-Verify federal work authorization program. The documentation that was previously provided included the following.
The E-Verify Employment Eligibility Verification page OR a page from the E-Verify Memorandum of Understanding (MOU) listing the bidders/contractors name and the MOU signature page completed and signed by the bidder/contractor and the Department of Homeland Security Verification Division
A current, notarized Affidavit of Work Authorization (must be completed, signed, and notarized within the past twelve months).
Name of Missouri State Agency or Public University* to Which Previous E-Verify Documentation Submitted: _____________________________________________________________________
(*Public University includes the following five schools under chapter 34, RSMo: Harris-Stowe State University St. Louis; Missouri Southern State University Joplin; Missouri Western State University St. Joseph; Northwest Missouri State University Maryville; Southeast Missouri State University Cape Girardeau.)
Date of Previous E-Verify Documentation Submission: ______________________
Previous Bid/Contract Number for Which Previous E-Verify Documentation Submitted: ___________________
(if known)
Authorized Business Entity Representatives Name (Please Print)Authorized Business Entity
Representatives Signature
E-Verify MOU Company ID NumberE-Mail Address
Business Entity NameDate
FOR STATE USE ONLYDocumentation Verification Completed By:
BuyerDate
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