DeKalb County Board of Education (“Owner”) 1780 Montreal Road
Tucker, Georgia 30084
Phone 678-676-1320 Fax 678-676-1469
W
ORK
A
UTHORIZATION
Master Agreement for Services and Maintenance
The following number must appear on all related correspondence and invoices:
W.A. NUMBER:
Contractor:
[Name][Company] [Street Address] [City, ST ZIP Code] (the “Service Contractor”)
PROJECT/SCHOOL:
[Name][Company] [Street Address] [City, ST ZIP Code] (the “Project”) ADA (504) LSPR Maintenance Emergency Other
W.A. DATE REQUISITIONER Commencement Date Completion Date Payment & Performance Bond
YES NO
The Service Contractor shall provide the Owner the following Services with respect to the Project:
As part of its Services, the Service Contractor shall produce for and/or deliver to the Owner the following tangible products, goods or deliverables (examples: reports, plans, financial estimates, parts, equipment, materials, etc.)
(TOTAL OF ALL WORK AUTHORIZATIONS SHALL NOT EXCEED THE MAXIMUM AMOUNT PAYABLE UNDER THE CONTRACT AS SET FORTH IN ARTICLE 4, SECTION 4.1)
Contract Price:
The Contract Price for this Work Authorization is DOLLARS ($ ).
This Work Authorization incorporates by reference the MASTER AGREEMENT FOR SERVICES UNDER WORK AUTHORIZATION dated _________________, 20___ (including all Exhibits thereto);
Attachment “1” hereto, Immigration and Security Form and accompanying affidavits;
Attachment “2” the Service Contractor’s Insurance Certificate(s); and, the following (if any): Attachment “3” the Service Contractor’s Quotation/Proposal
(all of which are collectively referred to as the Contract Documents for the Project).
IN WITNESS WHEREOF, the Owner and the Service Contractor, intending to be legally bound and each acting through persons duly authorized, have placed their signatures on duplicate original copies of this Contract.
DeKalb County Board of Education Service Contractor
Crawford Lewis, PHD. Legal Name of Contractor Superintendent
Patricia A. Pope By Corporate Seal Chief Operations Officer
Date of Execution Title If this Work Authorization is $50,000 or more.
ATTACHMENT “1”
(REQUIRED TO BE COMPLETED BY ALL CONTRACTORS AND SUBCONTRACTORS FOR EACH WORK AUTHORIZATION)
IMMIGRATION AND SECURITY FORM
A. In order to insure compliance with the Immigration Reform and Control Act of 1986 (IRCA), Pub.L. 99-603 and the Georgia Security and Immigration Compliance Act O.C.G.A. § 13-10-90 et. seq., Contractor and all Subcontractors must initial one of the sections below:
______ Contractor has 500 or more employees and Contractor warrants that Contractor has complied with the Immigration Reform and Control Act of 1986 (IRCA) Pub.L. 99-603 and the Georgia Security and Immigration Compliance Act by registering
at https://www.vis-dhs.com/EmployerRegistration and verifying information of all new
employees; and by executing any affidavits required by the rules and regulations issued by the Georgia Department of Labor set forth at Rule 300-10-1-.01 et. seq.
______ Contractor has 100-499 employees and Contractor warrants that no later than July 1, 2008, Contractor will register at https://vis-dhs.com/EmployerRegistration to verify information of all new employees in order to comply with the Immigration Reform and Control Act of 1986 (IRCA) Pub.L. 99-603 and the Georgia Security and Immigration Compliance Act; and by executing any affidavits required by the rules and regulations issued by the Georgia Department of Labor set forth at Rule 300-10-1-.01 et. seq.
______ Contractor has 99 or fewer employees and Contractor warrants that no later than July 1, 2009, Contractor will register at
https://vis-dhs.com/EmployerRegistration to verify information of all new employees in order to
comply with the Immigration Reform and Control Act of 1986 (IRCA), Pub.L. 99-603 and the Georgia Security and Immigration Compliance Act; and by executing any affidavits required by the rules and regulations issued by the Georgia Department of Labor set forth at Rule 300-10-1-.01 et. seq.
B. Contractor warrants that Contractor has included a similar provision in all written agreements with any subcontractors engaged to perform services under its Contract(s) with the DeKalb County Board of Education.
_________________________________ ___________________________________ Signature Title
Firm Name:_____________________________________________________________ Street/Mailing Address: ___________________________________________________
CONTRACTOR AFFIDAVIT
By executing the affidavit, the undersigned contractor verifies its compliance with O.C.G.A. 13-10-91, stating affirmatively that the individual, firm or corporation which is engaged in the physical performance of services under a contract with __________________________________________ (name of contractor) on behalf of __________________________________________ (name of public employer) has registered with and is participating in a federal work authorization program* [any of the electronic verification of work authorization programs operated by the United States Department of Homeland Security or any equivalent federal work authorization program operated by the United States Department of Homeland Security to verify information of newly hired employees, pursuant to the Immigration Reform and Control Act of 1986 (IRCA), P.L. 99-603], in accordance with the applicability provisions and deadlines established in O.C.G.A. 13-10-91.
_____________________________________________ EEV / Basic Pilot Program* User Identification Number
________________________________________ ____________ BY: Authorized Officer of Agent Date
(Contractor Name)
___________________________________________ Title of Authorized Officer or Agent of Contractor ____________________________________ Printed Name of Authorized Officer or Agent
SUBSCRIBED AND SWORN BEFORE ME ON THIS THE
________ DAY OF _______________, 20___ ____________________________
Notary Public
My Commission Expires:
____________________________
* As of the effective date of O.C.G.A. 13-10-91, the applicable federal work authorization
program is the “EEV / Basic Pilot Program” operated by the U.S. Citizenship and Immigration Services Bureau of the U.S. Department of Homeland Security, in conjunction with the Social Security Administration (SSA).
SUBCONTRACTOR AFFIDAVIT
By executing the affidavit, the undersigned subcontractor verifies its compliance with O.C.G.A. 13-10-91, stating affirmatively that the individual, firm or corporation which is engaged in the physical performance of services under a contract with __________________________________________ (name of contractor) on behalf of __________________________________________ (name of public employer) has registered with and is participating in a federal work authorization program* [any of the electronic verification of work authorization programs operated by the United States Department of Homeland Security or any equivalent federal work authorization program operated by the United States Department of Homeland Security to verify information of newly hired employees, pursuant to the Immigration Reform and Control Act of 1986 (IRCA), P.L. 99-603], in accordance with the applicability provisions and deadlines established in O.C.G.A. 13-10-91.
_____________________________________________ EEV / Basic Pilot Program* User Identification Number
___________________________________ _____ ____________ BY: Authorized Officer of Agent Date
(Subcontractor Name)
___________________________________________ Title of Authorized Officer or Agent of Subcontractor ____________________________________ Printed Name of Authorized Officer or Agent
SUBSCRIBED AND SWORN BEFORE ME ON THIS THE
________ DAY OF _______________, 20___ ____________________________
Notary Public
My Commission Expires:
____________________________
* As of the effective date of O.C.G.A. 13-10-91, the applicable federal work authorization program is the “EEV / Basic Pilot Program” operated by the U.S.
