Proposa I for

RFP No. 916 - Consultat im/Facilitation Services b r Developing Deer Management Plan

City of Ann Arbor Procurement Unit C/O Customer Service Desk First Floor, Guy C. Larcom Building 301 East Huron Street P.O. Box 8647 Ann Arbor, MI 481 07

Project Innovations, Inc. is a Michigan Corporation specializing in management consulting, currently in the 22nd year of business. We have built the company around our passion for collaboration, integrity and by delivering unflinching support to our clients in their times of greatest need.

PROJECT INNOVATIONS I N C O R P O R A T E D

A Management Consulting Firm for Business and Government

22000 Springbrook Ave., Suite 106 Farmington Hills, MI 48336

248-476-7577

I N C O R P O R A T E D .

Table of Contents

Page I I

Section A

Section B

Section C

Section D

Section E

Professional Qualifications

Past Involvement with Public Involvement Projects

Proposed Work Plan

Authorized Negotiator Letter

Appendices Insurance

= References Resumes Conflict of Interest Statement

P R O J E C T PTm- - - - r INNOVATfONS

Section A: Professional Qualifications

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PROJECT I N N O V A T I O N S I N C O R P O R A T E D o

Firm information

Prime Consultant

Project Innovations, Inc. (PI) 22000 Springbrook Ave., Suite 106 Farmington Hills, MI 48336

PI operates as a corporation and is licensed to operate in the State of Michigan.

Introduction to the Firm

Project lnnovations provides innovative solutions t o complex human problems. With more than 20 years of experience and a clientele that spans multiple industries, Project lnnovations continues to break through the limitations of traditional business practices. Our mission is t o assist business and government leaders as they navigate through uncertainty and make tough decisions. Whether it is a seasoned corporation, a budding entrepreneur, or a local city government, visionary founder Charles Fleetham has developed unique tools, such as our flagship method Unratio~al LeadershipTM.

The Five Principles of Unrational LeadershipTM

Start all problem-solving by taking personal responsibility. Aim at increasing energy, not just efficiency. Confront and partner with the unconscious. Creativity drives change. Look two generations behind and two generations ahead.

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PROJECT I.- '-- -- - .- INNOVATIONS I N C O R P O R A T E D

Key Personnel Summary

Charlie Fleetham, Project Innovations, Inc.

Greg DeLiso, Video Support, OKRaptor Productions

Primary Responsibilities: Relevant Experience & Expertise: Lead facilitator for Published author with more than 28 years of Stakeholder/Public meetings. experience in developing and implementing Responsible to Ann Arbor PM for successful public engagement strategies. client & task force satisfaction. Very experienced facilitator - recently Lead public engagement strategist. facilitated multi-million rate settlement Ensure successful completion of between Detroit Water & Sewerage Dept. project scope within proposed schedule and budget.

Kathy Anderson, Administrative, Project Innovations, Inc.

(DWSD) and Macomb/Oakland/Wayne Counties. Currently facilitating Ann Arbor's Sanitary Sewer Wet Weather Evaluation Project.

Primary Responsibilities: Shoot/edit/produce project close-out video.

Primary Responsibilities: Prepare meeting summaries, infographics, etc.

Relevant Experience & Expertise: Shotledited three videos for Ann Arbor on Footing Drain Disconnection, Wastewater Treatment Plant Operation, and developer offset mitigation.

Relevant Experience & Expertise: 20 years' experience in client focused administrative support/desktop publishing.

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. .

PROJECT I N N O V A T I O N S I N C O R P O R A T E D

Ability to Perform the Work - Project Innovations, Inc. (Prime Contractor)

Since 1992, Project lnnovations team members have worked alongside community stakeholders to help elected officials, administrators, and agency directors meet the needs of their communities. Having designed, planned and implemented strategic planning, visioning and community involvement projects for over 20 years, our team has a robust how-to "library." We know how to build citizen-administrator teams. We know how to integrate voices of opposition into the process. We know how to facilitate

-- - . collaborative solutions. And, we know how to communicate project results in writing and in video. Please use the YouTube URL's below or use your Smart phone (QR codes below) t o see our recent videos!

Bloomfield Hills Video: http://goo.gl/LBCaXG

Rates Simplification Video: http://goo.gl/iJgZc9

-

These "tags" connect to the videos. To use it,

download the free app from iTunes or use the web browser on your

phone at: http://gettag.mobi

We'll work with the City t o create meaningful, realistic desired outcomes; facilitate the Public Engagement Process t o achieve those outcomes, and summarize the results for the project record. We'll work with you t o make course corrections or overcome unanticipated obstacles. The result - an effective meeting process that achieves your desired outcomes. We facilitate all types of meetings, including:

All-Employee Meetings Team Organizations and Kick-Offs Partnering session meetings Problem-Solving Motivational Meetings Strategic Planning Sessions Brainstorming Sessions Company Kick-Offs Project Start-ups Visioning/Goal Setting Meetings

Best-in-Class Project Innovations PU- 1 Engagement Services

Employing automated audience response tools in large public meetings. Designinglmaintaining customer involvement databases. Public meeting videotapes and customized videotapes as needed. Mail-in surveys.

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PROJECT - - w - INNOVATIONS l N C O R P O R A T E D

Section B: Past Involvement with Similar Projects

Page 1 6

PROJECT INNOVATIONS I N C O R P O R A T E D

Detmit Water & Sewarap Dgpt. Fartneriw Detroit water & *werage mpt.~cul~uture Change Lansing Go mmunky College ~ e a d e h i p Training Michigan oept, of &gr icuM~e Custom- SR'Y~W A~&n~jr&

mchigan oept, of m i r m r n m a l o.uarlity c ~ ~ r S ? w - c e Training Michigan Dept. of Tramportation Partnefmg City of Rochester Hills Ssiening Wchigan Dept, of Natural Resources CYstomw 5miu.E Training Wayne cd~lnty wpt, of 1Envi.ronrnent cutkure ch- Wayne County Dawnriver Customer Partreering

city of Ann Arbor Water Master &I artwring Bl00mfie d Hi Ir schoo r strategic P

Canton Township ieadersh-p Fi

Chicago Water Dept Strategic I ning Dearborn Public Works Operational Planning Detroit Wastewater Partnership Trainimg Detroit Water &Sewerage Dept. Wholesale Customer ~artnering

nhl imunity Faciiiiat City of Farmington Hilb Conflict Management Trahnng city of rarmington Hi'ls Leadership Training

and H m n Charter Tp,ylCpgip Strategic Plan onal cammission strawgirc rlaqning

~ w i c e Training

r r t

State of Michigan Leadel 2cllr raining TRANSHUB - Regional Chamber of Commerce strategic R%n.ring University of M t ro i t Jesuit High W h m l strategic Plan

ayne County Sheriff's Office Management Training nrnf West.and Strategic P an'

rd County Intervention Ann nrbor sanitary sewer Wet \

City af Lansing Tramportatton Plannm 8.l'somfietd Hills School Garnmunity Partner-.,

field Hills School Foundation strategic Plan FaTmington visionin ~ l e Public Schools ~ t r a t e ~ y f l u=lprnazoo Ear y Retirepant initrz@iw Risk Accacsment

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Project !fame I 6Jood1ld Hills I Redford Twp. District I Str,stegic Plan I Library Strategic Pian

Client Phone Number 248-341-5406 I

Client Hame / Addre%

Contact Person R O W Gtdirjs I Lisa H w i g

BloomPieM Mtls School Districz, 7273 Wingtake Rd, Bloomfield Hills. MI 48301

Description Developed a 10-Year Strateg~c Plan Tar BioornfieM Hitls School Q~smcr, covering academ~~ community. facil'iy, and financ~al aspects.

RedfordTwp. District Library, 25310 W. Six Mile Rd, Redford. M I 48240

Dareloped a 5-Year Strategic Plan for Redf~~rd Iwp. Urswict Library

Start Date I November 2007 I f#arch 2012 I I

Overall / Final Budget 5125,R00/S149.680* I I U5.000/$15,000

I 1

Origicial Completion Date

Final Completion Wete/Budget Perforrurance

' Change orders requested/approxedat client request

June 2008 October 2012

luppo~ting Firmr

City of Farmington

June ZOOB/withm final budget

Vince Pastue

Caober ?Ol2/witfiln frnal budget

Wade 5r1m Associates. Dr Suzanne W~lson (MSU Education Dept.1 and Anderwn Consulting

Reltormrd strategic analysis of staff & organizational structure.

Wade T r ~ n Assoc~ates

January 2014

November -XU4

None

Outreach Weather Evaluation

M r o i t W,ater & C%y of Ann Arbor Sewerage Dept., 735 Randclph. Detroit, AtIl

Bill khnscn I l i c k Hutchinson

Develop and fac~lirare a wholesale water & s e w customer omreach program

Wade Trim Associates. Greeley & Mansen, Chelsea Environmental. Chris Webb. CMBMhill, C I X ? Smith, TYJT

Facilitatmg Citiiens; kdvisocy Committee In Saolta~y Sewer Wet Weather Evaluation Project

March 2003

S757(U0

March 2006/on-go~ng

On-going

Maanrovia Pictures, Famous in Your Field

February 2013

51112,860/5150,860'

On-going

On-going

PROJECT 7- I N N O V A T I O N S

-.

Section C: Proposed Work Plan

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7- PROJECT - .

I N N O V A T I O N S I N C O R P O R A T E D

Scope Summary (from RFP)

In response t o residents reporting deer causing damage t o landscaping, concerns regarding vehicleldeer collisions and the deer-borne diseases, the City Council directed the City Administrator t o partner with the Washtenaw County Parks and Recreation Department, the University of Michigan, the Humane Society of Huron Valley and other interested parties t o develop information and strategies needed for deer management and seek assistance from the Michigan Department of Natural Resources Wildlife Division. In response to this directive, the City Administrator provided the attached report (Attachment 1) t o the City Council. The next step in developing deer management plan is community engagement. The City is seeking services of a facilitator/consultant for assistance in Community Engagement and developing a community-endorsed deer management plan. Elements of this plan will include specific objectives of the program, delineation of deer management area, scope of public notification if lethal methods are used, public safety considerations, requirements for the use of lethal methods, etc.

Project Innovations Public Engagement Philosophy

Project Innovations' philosophy regarding public engagement is t o emotionally and physically engage the public early and often. Successful public engagement builds trust on two levels: 1) trust in the project team's technical competence and 2) the project team's willingness t o truly listen to the stakeholders. A well-publicized timeline, clearly established milestones, and easily accessible digital records offer transparency. Competently facilitated meetings and fruitful conversations will create a collaborative environment t o discuss complex topics in a safe space. The keys t o a successful public engagement project in Ann Arbor include:

1. Creating a safe space for the public t o raise and discuss the issues relating to tPe project. 2. Acknowledging feedback and showing how it is being utilized by the Project Team. 3. Preparing for meetings with a relevant agenda and providing facilitation that allows for all voices to

be heard. 4. Dissemirating information in various methods t o be sure that it is reaching a wide audience,

including stakeholders such as City Council, Commissions, and Boards.

5. Translating complex technical language into simplified and easy to digest documents.

Public Engagement Team Project Innovations' lead facilitator will be Charlie Fleetham; he will provide this project with outstanding facilitation of public meetings and irterviews. Project lnnovations will team with Greg DeLiso of OK Raptor Productions to create a close-out video summarizing the project results.

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PROJECT INNOVATIONS

-s I N C O R P O R A T E D

I. Public Engagement Work Plan

ccict i in^ a P ~ ~ h l i c

Key Sub-Tasks: To effectively engage interested stakeholders and communicate progress throughout the project, the key components of the public engagement strategy should include:

i. Situation Analysis - input from the City for data collection and the key issues to be addressed.

ii. Communication Objectives - clarify the City's key objectives for dissemination of information and

engagement of stakeholders. iii. Message Model -identify the key messages that must be communicated to ensure stakeholder

participation and introduction to the project team's competencies.

iv. Target Audience Lists - develop a comprehensive list of stakeholders, City staff, media, and other

influencers.

v. Engagement Timeline - determine timing to conduct meetings and provide interim and final

reports.

vi. Risk Analysis - identification of aggrieved stakeholder groups which may require alternative

communication strategies.

vii. Project Management Website - establish a project management website to store project documents and calendars.

viii. Media Strategy - establish a balanced strategy to disseminate information using appropriate electronic and print methods to reach target audiences.

ix. Public Engagement Milestones - depict the interaction of all elements of the above mentioned

strategy.

Delivera bles:

Public Engagement Strategy Outline

Staff Members:

Charlie Fleetham - 4 hours

Information Required from City:

Historical Data Project Data Meeting with Project Manage

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PROJECT INNOVATIONS I N C O R P O R A T E D

Key Sub-Tasks:

i. Outline Outreach Plan for obtaining feedback ii. Outline presentations for public meetings iii. ldentify stakeholders from other public agencies iv. ldentify necessary timeline for updating stakeholders

v. Finalize presentations to stakeholders and public

Delivera bles:

Completed Public Engagement Strategy

Staff Members:

Charlie Fleetham - 8 hours Kathy Anderson - 4 hours

Information Required from City:

Project Manage edits/approves strategy

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PROJECT INNOVATIONS I N C O R P O R A T E D

l c : Engage the I

Key Sub-Tasks: i. Conduct Stakeholder meetings or interviews, including

Washtenaw County Parks and Recreation University of Michigan MDNR -Wildlife Managements Humane Society of Huron Valley Others as identified

ii. Conduct Public Meeting #1 t o gather feedback on alternatives iii. Analyze Feedback with Key Stakeholders iv. Conduct Public Meeting #2 to Present Alternatives v. Update Project Website

Delivera bles:

Summary of Stakeholder Interviews = Summaries of Public Meetings #1& #2

Staff Members:

Charlie Fleetham - 40 hours Kathy Anderson - 8 hours

Information Required from City:

= Stakeholder List Input into Public Meeting Agenda Draft Presentations for Public Meetings

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PROJECT INNOVATIONS

Id : Create and Distribute Public Engagement Materii

Key Su b-Tasks: We will create the following materials:

Project description with graphics Press releases for Public Meetings lnfographics showing Deer Management Situation Public Meeting Powerpoint slides Public Meetings agendalsummaries Project close-out video (4-5 minutes)

Deliverables: (as noted above)

Staff Members:

Charlie Fleetham - 12 hours = Kathy Anderson - 16 hours

Greg DeLiso (OKRaptor Productions)

Information Required from City:

Input for Public Engagement materials as noted above

II. Document Public Engagement Activities (included in Task I)

The following documents will be created, distributed and arclived as part of the public engagement process: Project Plan, Project Working Group Meeting Summaries, Meeting Agendas, Meeting Presentations, Supporting Dscuments, Public Meeting Summary of Findings and Interview Summary of Findings.

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PROJECT INNOVATIONS I

ill. Assist in Developing a Deer Management Plan

Coordinating with the Project Manager, we will assist in developing the plan as follows: i. Developing outline ii. Developing executive summary iii. Creating infographics iv. Drafting/editing document as needed

Delivera bles:

Draft Deer Management Plan, including: Executive Summary Draft Powerpoint of plan

Staff Members:

Charlie Fleetham - 12 hours

Information Required from City:

Input as noted above

Page ( 15

PROJECT p- IINNOVATIONS I N C O R P O R A T E D I--..

Section D: Authorized Negotiator Letter

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PROJECT F2 L

L.. I

INNOVATIOINS

September 22,2014

City of Ann Arbor Procurement Unit c/o Customer Service Desk First Floor, Guy C. Larcom Building 301 East Huron Street P.O. Box 8647 Ann Arbor, MI 48107

Re: RFP No. 916: Consultation/Facilitation Services for Developing Deer Management Plan Proposal

This letter confirms that Charles Fleetham is authorized t o negotiate, discuss and in any other way communicate with the City of Ann Arbor staff regarding RFP No. 916: Consultation/Facilitation Services for Developing Deer Management Plan.

This letter will further authorize Charles Fleetham to act in all matters on behalf of Project Innovations.

Therefore, by existence of this instrument we hereby authorize Charles Fleetham to accept or reject agreements, t o enter into contracts binding upon, and to act in whatever way necessary so as to accomplish that which is being undertaken regarding this project.

Very Truly Yours,

Charles Fleetham, President Project Innovations, Inc. 22000 Springbrook Ave., Suite 106 Farmington Hills, MI 48336 248-476-7577 charlie@~ro~ectinnovations.com

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PROJECT I-- . - IIL - .

I N N O V A T I O N S . I N C O R P O R A T E D ..-

Section E: Appendices

Page 1 18

PROJECT . . INNOVATIONS I K C Q R P O R A T E D

Insurance

As a Michigan domiciled corporation, Project lnnovations Inc. carries reasonable and appropriate insurance coverage. Upon selection, Project lnnovations will provide a copy of i t s declaration page to clarify the available liability coverage.

References

Project Innovations (PI) has worked on hundreds of facilitation assignments for a broad array of clients across the public and private sector. These efforts feature dimensions that are essential for a successful group facilitation - shared visions and aspirations, measurable goals and timelines, collaborative stakeholder and public involvement, scenario brainstorming, contingency planning, roles and responsibility clarification, and successior- planning.

Below are three references. We encourage you t o contact these satisfied clients for a firsthand appraisal of our creativity, technical expertise, and performance in meeting project goals. We would be happy to provide information on additional projects if requested.

Lisa Hoenig, Director Redford Township District Library 313-531-2640 Ihoenig@redfordlibrary.or~

Mr. Vince Pastue City Manager, Farmington 248-302-1824 VPastueQci.farmiWon.mi,u~

Ms. Sue McCormick Director Detroit Water and Sewerage Department 313-224-4703 mccormic@dwsd.org

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-- PROJECT 8-

INNOVATIONS I N C O R P O R A T E D

Project Innovations, lnc. Founder and President

As a successful management consultant, author, speaker, and trainer for over twenty years, Charles has a storehouse of expertise in leadership development, organizational change, and strategic planning. He has helped many public sector clients develop strategic plans, including Bloomfield Hills Schools, City of Kalamazoo, Detroit Water and Sewerage Department, Michigan Technological University, and Wayne County Department of Environment.

In 2000, he began to integrate the theories of Dr. Carl Jung into his consulting practice because he saw two things: most leadership and organizational development practices were based on worn out traditional thinking and that the most powerful sources of creativity and energy were stored in the unconscious. Based on Jung's ideas and his own experience, he developed the Unrational LeadershipTM process to leverage the unconscious for growth and change.

A graduate of Michigan State University, Charles received a BA in English with High Honors. Considered an expert in group dynamics and resolving large-scale organizational conflict, Charles has broadly implemented the concepts of Unrational LeadershipTM in business and government. Although these ideas are counterintuitive to the organizational mind, Charles has seen more and more of his clients successfully adopt this innovative way of thinking and doing.

Charles is the author of The Search for Unrational Leadership: Using Rational& lrrational Methods To Change Your Life -Right Brain Books (2005) and co-author of Asya's Laws-Right Brain Books (2006).

He has had many articles published, including:

Bought, and Waiting for the Ax to Fall - The New York Times Consultant Holds Key to Business Potential - Oakland Business Review lrrational Secrets to lnnovations - HR Magazine Merger Therapy: Help employees embrace M & A Change - Insight Michigan a t the Crossroads: Five Strategies for Economic Revival - The Michigan Citizen Michigan's Automotive Leadership A Time for "Lobe"-trotting - IndustryWeek.com Process Performance Management for Short-term Staff - Workforce Performance Solutions Southern Strategy - Crain's Detroit Business Tapping the Unconscious for Results - Consulting to Management (C2M) Unleash the Hidden Potentialin Your Business - Business Week Unleash the Innovator Within - Entrepreneur.com Unrational Methods Boost Revenue and Build Leaders - IOMA Use Unconscious in Decision Making - Industry US Business Journal Online

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1. Y

PROJECT INNOVATIONS

Pmject Inno~atiuwi Inc. Freelance dto~,t'DP~direc tor Cadact: Chaalie Fleet-

MTV Network4 (2005-20 10) Fmlaarce videogapher/editor on v,uious co rnc i a1 and In-home projects. Contact: Mark Breese

Fedatov Productions (2009-present) Editor Contact: Elcena Sph&

Found Footage Festival (2009-present) Contributing e&trli7iriter/DP/director for daily . r i d video csntent and with the towing live show. i~~~~~found,~oatagefest.coru Contact: Mick Prueher 31 Joe Pickett

Howcast Inc cZ009-20 11) Editofi~DP~dircctor for original online c,ontent. ~~~~w-.hoi~cast.com~~i~er~lgreg&li~~

A& Tram ('2009). Served as DP for rl.re MarhOnAirtan viral series. i.rr~~-.marksnair&.mconl

Runners World Magazine (2007-2008) EditorDPlproducerldirector for online content. Serr'ed as a consultant druiig the launching stages of their online video content. Since my in~olvement their traffic bas grown exponentially from the thousands to millions each month. Ccntact: I3ri.m Sabk

Imaginasisn TY (1005-2007) Senred ss DPIeditor for conm1ercials atld original programming.

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ATTACHMENT C

LEGAL STATUS OF RESPONDENT

(The Respoildent shall fill out the appropriate form and strike out the other three.)

By signing below the authorized representative of the Respondent hereby certifies that:

The Respondent is: A corporation organized and doing business under the laws of the state of

h Id& &A , for whom L k e f k s Fl&earing the office title of f ~ , &.&& , whose signature is affixed to this proposal, is authorized to execute contracts on behalf of respondent.*

*If not incorporated in Michigan, please attach the corporation's Certificate of Authority - A limited liability company doing business under the laws of the state of

whom bearing the title of

, whose signature is affixed to this

proposal, is authorized to execute contract on behalf of the LLC.

A partnership organized under the !aws of the state of

, and filed with the county of ,

whose members are (attach list including street and mailing address for each.)

- An individual, whose signature with address, is affixed to this RFP.

Respondent has examined the basic requirements of this RFP and its scope of services, including all Addendum (if applicable) and hereby agrees to offer the services as specified in the RFP.

LCLPK.einn.L% Date: s -14 -/? Signature

(Print) Name

Firm: -be' -- - --.

Address: 2z000 Fax Z.t(a * Q ~ ~ * L s L J ~

ATTACHMENT C CITY OF ANN ARBOR

LIVING WAGE ORDINANCE DECLARATION OF COMPLIANCE

The Ann Arbor Living Wage Ordinance (Section 1:811-1:821 of Chapter 23 of Title I of the Code) requires that employers providing services to the City or recipients of grants for financial assistance (in amounts greater than $10,000 in a twelve- month period of time) pay their employees who are working on the City project or grant, a minimum level of compensation known as the Living Wage. This wage must be paid to the employees for the length of the contractlproject.

Con7panies employing fewer than 5 persons ard nor,-prcfits employing fewer than 10 persons are exempt from the Ordinance. If this exemption applies to your firm, please check below:

This cornwny is exempt due to the fad that we employ or contract with fewer than 5 individuals. This non-profit aqencv is exempt due to the fact that we employ or contract with fewer than 10 employees.

The Ordinance requires that all contractors/vendors and/or grantees agree to the foliowing terms:

a) To pay each of its employees performing work on any covered contract or grant with the City, no less than the living wage, which is defined as $12.70/hour when health care is provided, or no less than $14.18/hour for those employers that do not provide health care. It is understood that the Living Wage will be adjusted each year on April 30, and covered employers will be required to pay the adjusted amount thereafter. The rates stated above include any adjustment for 20:4.

b) Please check the boxes below which apply to your workforce:

Employees who are assigned to any covered City project or grant will be paid at or above the applicable living wage without health benefits Yes No___

who are assigned to any c v red City project or grant will be paid at or above the applicable living wage with health benefits Yes No

c) To post a notice approved by the City regarding the Living Wage Ordinance in every work place or other location in which e.nployees or other persons contracting for employment are working.

d) To provide the City payroll records or other documentation as requested; and,

e) To permit access to work sites to City representatives for the purposes of rronitoring compliance, investigating complaints or non-compliance.

The undersigned authorized representative t-ereby obligates the contractor/vendor or grantee to tne above stated conditions under penalty of perjury and violation of the Ordinance.

Signature of Authorized Representative

Address. City. State. Zip F w , f i f7LLT & ( e 3 L Phone (area code)

Ernail address

Date signed Questions about this farm? Please contact;

Procuremert Office City of Ann Arbor Phone: 734!7S4-6500

Revised 312014 rev.O

Questions about this form? Call the Procurement Office: (734)794-6576

CITY OF ANN ARBOR PROCUREMENT OFFICE Form #I HUMAN RIGHTS CONTRACT COMPLIANCE FORM

Address - (Street address) (Area Code)

Fax#_---- -- (Area Code)

EMPLOYMENT DATA

AAF- 1

Job Categories Number of Employees

( ~ e p a r t a t e c a t e g o w l

Male

-

-----------

t I

Female Natwe Hawallan or Other Pac~fic

Islander

K

--- --

White

------------- G

Natlve Hawaitan or

Other Pac~fic Islander E

H~spanrc a Lat~no

D - -

--------

A

Exec/Sr Level O f f l c~a l s

Supervisors

P ro fess~ona l s

Techn~c~ans ------

I - 3 -- I

As an

I

Black or Afncan

Amencan

H

Amencan lnd~an or Alaska Natwe

F

I

-----

American lndlan or Alaskan

Nahe

L

Hlspan~c or Lat~no

J

Black a Afr~can

Amertcan

B

TOTAL COLUMNS

A-L

Asian

C

Sales

Adrnln Support

Craftspeople

O p e r a t ~ v e s

Se l v l ce Worke rs

LaborersIHelper

Apprentices

Other

TOTAL

PREVIOUS

I a

YEAR TOTAL

. .- .. - , -

PROJECT 2 - INNOVATIONS

Vendor Conflict of lnterest Disclosure Form

All vendors interested in conducting business with the City of Ann Arbor must complete and return the Vendor Conflict of lnterest Disclosure Form in order to be eligible to be awarded a contract. Please note that all vendors are subject to comply with the City of Ann Arbor's conflict Tnterest policies as staled within the certification section below.

If a vendor has a relationship with a City of Ann Arbor official or employee, an immediate family member of a City of Ann Arbor official or evployee, the vendor sttall disclose the rnformation required below.

Certification: I hereby certify that to my knowledge, there is no conflict of interest involving the vendor named below:

1. No City official or employee or City employee's immediate family member has an ownership interest in vendor's company or is deriving personal financial gain from this contract.

2. No retired or separated City official or employee who has been retired or separated from the City for less than one (I) year has an ownership interest in vendor's Company.

3. No City employee is contemporaneously employed or prospectively to be employed with the vendor.

4. Vendor hereby declares it has not and will not provide gifts or hospitality of any dollar value or any other gratuities to any City employee or elected official to obtain or maintain a contract.

5. Please note any exceptions below:

I Vendor Name I Vendor Phone Number I

Conflict of lnterest Disclosure *

there maybe a poten!ial conflict of interes'.

I 'Disclosing a potential conflict of Interest does not disqual~fy vendors. In the event vendors do not disclose potential conflicts of interest and they are detected by the City, vendor will be exempt from doing business with the City.

I certify that the information provided is true and correct by my signature below:

Sept. 22. 2104 C ~ ~ A R Tit f#~,q -

Signature of Vendor Authorized Representative

.I

Date Printed Name of Vendor Authorized Representative

PROCUREMENT USE ONLY

Yes. named employee was lnvolved in Bld I Proposal process

No, named employee was not involved in procurement process or decision.

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