Subcontractor & Material Supplier Declaration (DB) The Ohio State University Facilities Operations and Development fod.osu.edu 400 Enarson Classroom Bldg, 2009 Millikin Road, Columbus, OH 43210 Phone: 614.292-4458 Fax: 614.292-2539

The intent of this form is to confirm the companies submitted have been reviewed, appear to be Responsible, and are proposing to provide the services/material goods listed in compliance with the Contract Documents. Instructions 1. The Ohio State University Responsibilities: Pending = EDGE application submitted to EOD and waiting for response. A. Provide a downloadable copy for contractors via internet at Mentor = Special category of participation within the EDGE program. http://fod.osu.edu/vendor/. Scroll down to Construction. Protégé = Special category of participation within the EDGE program. K. Certify form by signing in the space provided and e-mail or fax to the A/E, 2. Contractor Responsibilities: OSU, for review. A. Use the form provided by OSU as a master for the project. Creation of 3. A/E Review: additional pages electronically or by photocopying is permitted. A. Review form in collaboration with OSU. B. Complete all required information for each Subcontractor and Material B. When consensus is reached, sign in the space provided and e-mail or fax the Supplier. (Attach additional sheets as necessary.) Second and third tier form to the OSU. Subcontractors of Material Suppliers who may provide on site labor must be identified as Subcontractors. 4. Ohio State University Approval: C. Check company type as a Subcontractor or Material Supplier. A. Verify DFSP enrollment, including supporting documentation, if applicable. D. Enter company name, address, phone number, fax number, federal tax I.D. B. Verify current EDGE-certified status using the EOD Web site. number and e-mail address. C. Complete “For Cont. Auth. Use Only” section in the order indicated below E. Indicate the primary company officer (e.g., President, Owner) and contact 1. Determine status of companies listed on each sheet received. person. a. When one or more companies require “Extended Review”: mark F. Enter the date and amount of subcontracts and purchase orders. company status for each, and then go to C2. G. Enter a brief description of the type of work to be performed by the b. When one or more companies are rejected: mark company status for Subcontractor. Enter a brief description of the services/material brands being each, and then go to C3. supplied by the company. Attach additional sheets as necessary with clear c. When all companies are approved: mark company status for each, descriptions. and then go to C4. H. Complete “DFSP Enrolled” section. Contractors, Subcontractors and Material 2. Forward a copy of the annotated form to the Contractor as its notice of the Suppliers providing labor on a state construction project site must be enrolled Extended Review; then, proceed to perform and complete the Extended in the BWC Drug-Free Safety Program (DFSP) or BWC-approved DFSP prior Review. When completed, mark form as appropriate, and process per C1b to performing work on the site. Submit supporting documentation or C1c. demonstrating approval status for a BWC-approved DFSP. 3. Prepare written documentation of basis for rejection and insert it into the I. Enter the DFSP policy number. project file, and if appropriate, insert a copy into the “responsibility review J. Complete “EDGE Status” section. See the EDGE Web site for any questions at file” for the particular company; and then go to C4. www.EDGE.ohio.gov: 4. Forward a copy of the annotated form to the A/E, Contractor, and CM, if Certified = EDGE-certified by Equal Opportunity Division (EOD). applicable. Insert the original form into the “Project file.”

0140_Subcontractor_and_Material_Supplier_Declaration.doc SAO-F310-01v1211 1Attach additional sheets as necessary. 2Check all that apply. Page 1 of 6 Subcontractor & Material Supplier Declaration (DB) The Ohio State University Facilities Operations and Development fod.osu.edu 400 Enarson Classroom Bldg, 2009 Millikin Road, Columbus, OH 43210 Phone: 614.292-4458 Fax: 614.292-2539

She Design Build (DB) Information Subcontractor Information of et1 DB Co. Name Subcontractor Address Address City, State, Zip City, State, Zip Project Name Contract Type Project No. Federal Tax ID DFSP Enrolled: Yes No

Subcontractor Material Subcontractor Material Supplier Subcontractor Material Supplier Supplier (check one) (check one) (check one) Company Name Street Address City/State/Zip Telephone No. Fax No. Federal Tax I.D. No. E-mail Address

Primary Officer Contact Person Subcontract/P.O. Date Subcontract/P.O. Amount $ Services/Material Brands1 Skilled Trade License No.

DFSP Enrolled Yes No (when supplying labor on Yes No (when supplying labor on Yes No (when supplying labor on site) site) site) DFSP Policy No. EDGE Status2 Certified Pending Mentor Certified Pending Mentor Certified Pending Mentor Protégé Protégé Protégé

For Cont. Auth. Use Only Approved Extended Review Approved Extended Review Approved Extended Review Rejected Rejected Rejected

Subcontractor Certification DB Review A/E Review Ohio State University Approval

0140_Subcontractor_and_Material_Supplier_Declaration.doc SAO-F310-01v1211 1Attach additional sheets as necessary. 2Check all that apply. Page 2 of 6 Subcontractor certifies that the information DB has reviewed the information above and A/E has reviewed the information above and Subcontractors and Material Suppliers are above is true and complete. finds it in compliance with the Contract finds it in compliance with the Contract accepted, as shown or as noted, for use on Documents as shown or as noted. Documents as shown or as noted. this project subject to revocation for cause.

Signature Date Signature Date Signature Date Signature Date

0140_Subcontractor_and_Material_Supplier_Declaration.doc SAO-F310-01v1211 1Attach additional sheets as necessary. 2Check all that apply. Page 3 of 6 Subcontractor & Material Supplier Declaration (DB) The Ohio State University Facilities Operations and Development fod.osu.edu 400 Enarson Classroom Bldg, 2009 Millikin Road, Columbus, OH 43210 Phone: 614.292-4458 Fax: 614.292-2539

She Design Build (DB) Information Subcontractor Information of et1 DB Co. Name Subcontractor Address Address City, State, Zip City, State, Zip Project Name Contract Type Project No. Federal Tax ID DFSP Enrolled: Yes No

Subcontractor Material Subcontractor Material Supplier Subcontractor Material Supplier Supplier (check one) (check one) (check one) Company Name Street Address City/State/Zip Telephone No. Fax No. Federal Tax I.D. No. E-mail Address

Primary Officer Contact Person Subcontract/P.O. Date Subcontract/P.O. Amount $ Services/Material Brands1 Skilled Trade License No.

DFSP Enrolled Yes No (when supplying labor on Yes No (when supplying labor on Yes No (when supplying labor on site) site) site) DFSP Policy No. EDGE Status2 Certified Pending Mentor Certified Pending Mentor Certified Pending Mentor Protégé Protégé Protégé

For Cont. Auth. Use Only Approved Extended Review Approved Extended Review Approved Extended Review Rejected Rejected Rejected

Subcontractor Certification DB Review A/E Review Ohio State University Approval

0140_Subcontractor_and_Material_Supplier_Declaration.doc SAO-F310-01v1211 1Attach additional sheets as necessary. 2Check all that apply. Page 4 of 6 Subcontractor certifies that the information DB has reviewed the information above and A/E has reviewed the information above and Subcontractors and Material Suppliers are above is true and complete. finds it in compliance with the Contract finds it in compliance with the Contract accepted, as shown or as noted, for use on Documents as shown or as noted. Documents as shown or as noted. this project subject to revocation for cause.

Signature Date Signature Date Signature Date Signature Date Subcontractor & Material Supplier Declaration (DB) The Ohio State University Facilities Operations and Development fod.osu.edu 400 Enarson Classroom Bldg, 2009 Millikin Road, Columbus, OH 43210 Phone: 614.292-4458 Fax: 614.292-2539

She Design Build (DB) Information Subcontractor Information of et1 DB Co. Name Subcontractor Address Address City, State, Zip City, State, Zip Project Name Contract Type Project No. Federal Tax ID DFSP Enrolled: Yes No

Subcontractor Material Subcontractor Material Supplier Subcontractor Material Supplier Supplier (check one) (check one) (check one) Company Name Street Address City/State/Zip Telephone No. Fax No. Federal Tax I.D. No. E-mail Address

Primary Officer Contact Person Subcontract/P.O. Date Subcontract/P.O. Amount $ Services/Material Brands1 Skilled Trade License No.

DFSP Enrolled Yes No (when supplying labor on Yes No (when supplying labor on Yes No (when supplying labor on site) site) site) DFSP Policy No. EDGE Status2 Certified Pending Mentor Certified Pending Mentor Certified Pending Mentor Protégé Protégé Protégé 0140_Subcontractor_and_Material_Supplier_Declaration.doc SAO-F310-01v1211 1Attach additional sheets as necessary. 2Check all that apply. Page 5 of 6 For Cont. Auth. Use Only Approved Extended Review Approved Extended Review Approved Extended Review Rejected Rejected Rejected

Subcontractor Certification DB Review A/E Review Ohio State University Approval Subcontractor certifies that the information DB has reviewed the information above and A/E has reviewed the information above and Subcontractors and Material Suppliers are above is true and complete. finds it in compliance with the Contract finds it in compliance with the Contract accepted, as shown or as noted, for use on Documents as shown or as noted. Documents as shown or as noted. this project subject to revocation for cause.

Signature Date Signature Date Signature Date Signature Date

0140_Subcontractor_and_Material_Supplier_Declaration.doc SAO-F310-01v1211 1Attach additional sheets as necessary. 2Check all that apply. Page 6 of 6