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HomeMy WebLinkAboutResolution - 2019-R0405 - Life Extension Clinics Dba Life Scan Wellness Centers - 11/05/2019 Resolution No. 2019-RO405 Item No. 6.15 November 5,2019 RESOLUTION BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK: THAT the Mayor of the City of Lubbock is hereby authorized and directed to execute for and on behalf of the City of Lubbock, Service Contract No. 14921 by and between the City of Lubbock and Life Extension Clinics, Inc., dba Life Scan Wellness Centers of Tampa, Florida, for Annual Firefighter Medical Physicals and Wellness exams as per RFP 20-14921-SG, and related documents. Said Contract is attached hereto and incorporated in this resolution as if fully set forth herein and shall be included in the minutes of the City Council. Passed by the City Council on November 5, 2019 DANIEL M. POPE, AYOR ATTEST: Reb cca Garza, City S re APPROVED AS TO CONTENT: g--C— -��A— Shaun Fog&r 6n, Fire Chief APPROVED A7;x Zdocs/RES. , A s t3�Cit At rney S ice Confract 14921-Annual Firefighter Medical Physicals and Wellness Exams 2 19 Resolution No. 2019-R0405 Contract 14921 City of Lubbock,TX Annual Firefighter Medical Physicals and Wellness Exams Agreement This Service Agreement(this"Agreement") is entered into as of the 5thday of November 2019 ("Effective Date") by and between Life Extension Clinics, Inc. dba Life Scan Wellness Centers (the Contractor), and the City of Lubbock(the"City"). RECITALS WHEREAS,the City has issued a Request for Proposals 20-14921-SG,Annual Firefighter-Medical Physicals and Wellness Exams. WHEREAS, the proposal submitted by the Contractor has been selected as the proposal which best meets the needs of the City for this service;and WHEREAS, Contractor desires to perform as an independent contractor to provide Annual Firefighter Medical Physicals and Wellness Exams, upon terms and conditions maintained in this Agreement; and NOW THEREFORE, for and in consideration of the mutual promises contained herein,the-City and Contractor agree as follows: City and Contractor acknowledge the Agreement consists of the following exhibits which are attached hereto and incorporated herein by reference, listed in their order of priority in the event of inconsistent or contradictory provisions: 1. This Agreement 2. Exhibit A—General Requirements 3. Exhibit B—Best and Final Offer 4. Exhibit C—Insurance Scope of Work Contractor shall provide the services that are specified in Exhibit A. The Contractor shall comply with all the applicable requirements set forth in Exhibit B, and C attached hereto. Article 1 1.1 The contract shall be for a term of one year,with the option of four,one-year extensions,said date of tern beginning upon formal approval.All stated annual quantities are approximations of usage during the time period to be covered by pricing established by this bid. Actual usage may be more or less. Order quantities will be determined by actual need.The City of Lubbock does not guarantee any specific amount of compensation, volume, minimum, or maximum amount of services under this bid and resulting contract. The Contractor must maintain the insurance coverage required during the tern of this contract including any extensions. It is the responsibility of the Contractor to ensure that valid insurance is on file with the Purchasing and Contract Management Department as required by contract or contract may be terminated for non-compliance. 1.2 The Contractor shall not assign any interest in this Agreement and shall not transfer- any interest in the Agreement,whatsoever,without prior consent of the City. 1.3 All funds for payment by the City under this Agreement are subject to the availability of an annual appropriation for this purpose by the City. In the event of non-appropriation of funds by the City Council of the City of Lubbock for the goods or services provided under the Agreement, the City will terminate the Agreement, without termination charge or other liability, on the last day of the then-current fiscal year or when the appropriation made for the then-current year for the goods or services covered by this Agreement is spent,whichever event occurs first. If at any time funds are not appropriated for the continuance of this Agreement, cancellation shall be accepted by the contractor on 30 days prior-written notice, but failure to give such notice shall be of no effect and the City shall not be obligated under this Agreement beyond the date of termination. 1.4 This contract shall remain in effect until the first of the following occurs: (1) the expiration date, (2)performance of services ordered, or(3) termination of by either party with a 30 day written notice. The City of Lubbock reserves the right to award the canceled contract to the next lowest and best bidder as it deems to be in the best interest of the city. Article 2 Miscellaneous. 2.1 This Agreement is made in the State of Texas and shall for all purposes be construed in accordance with the laws of said State, without reference to choice of law provisions. 2.2 This Agreement is performable in, and venue of any action related or pertaining to this Agreement shall lie in, Lubbock, Texas. 2.3 This Agreement and its Exhibits contains the entire agreement between the City and Contractor and supersedes any and all previous agreements, written or oral, between the parties relating to the subject matter hereof. No amendment or modification of the terms of this Agreement shall be binding upon the parties unless reduced to writing and signed by both parties. 2.4 This Agreement may be executed in counterparts, each of which shall be deemed an original. 2.5 In the event any provision of this Agreement is held illegal or invalid, the remaining provisions of this Agreement shall not be affected thereby. 2.6 The waiver of a breach of any provision of this Agreement by any parties or the failure of any parties otherwise to insist upon strict performance of any provision hereof shall not constitute a waiver of any subsequent breach or of any subsequent failure to perform. 2.7 This Agreement shall be binding upon and inure to .the benefit of the parties and their- respective heirs, representatives and successors and may be assigned by Contractor or the City to any successor-only on the written approval of the other party. 2.8 All claims, disputes, and other matters in question between the Parties arising out of or relating to this Agreement or the breach thereof, shall be formally discussed and negotiated between the Parties for resolution. In the event that the Parties are unable to resolve the claims, disputes, or other matters in question within 30 days of written notification from the aggrieved Party to the other Party, the aggrieved Party shall be free to pursue all remedies available at law or in equity. 2.9 At any time during the term of the contract, or thereafter, the City, or a duly authorized audit representative of the City or the State of Texas, at its expense and at reasonable times, reserves the right to audit Contractor's records and books relevant to all services provided to the City under this Contract. In the event such an audit by the City reveals any errors or overpayments by the City, Contractor shall refund the City the full amount of such overpayments within 30 days of such audit findings, or the City, at its option, reserves the right to deduct such amounts owing the City from any payments due Contractor. 2.10 The City reserves the right to exercise any right or remedy to it by law, contract, equity, or otherwise, including without limitation,the right to seek any and all forms of relief in a court of competent jurisdiction. Further, the City shall not be subject to any arbitration process prior to exercising its unrestricted right to seek judicial remedy.The remedies set forth herein are cumulative and not exclusive, and may be exercised concurrently. To the extent of any conflict between this provision and another provision in, or related to,this do. 2.11 The contractor shall not assign or sublet the contract, or any portion of the contract, without written consent from the Director of Purchasing and Contract Management. Should consent be given, the Contractor shall insure the Subcontractor or shall provide proof of insurance from the Subcontractor that complies with all contract Insurance requirements document,this provision shall control. 2.12 Contractor acknowledges by supplying any Goods or Services that the Contractor has read, fully understands,and will be in full compliance with all terms and conditions and the descriptive material contained herein and any additional associated documents and Amendments. The City disclaims any terms and conditions provided by the Contractor unless agreed upon in writing by the parties. In the event of conflict between these terms and conditions and any terms and conditions provided by the Contractor, the terms and conditions provided herein shall prevail. The terms and conditions provided herein are the final terms agreed upon by the parties, and any prior conflicting terms shall be of no force or effect. 2.13 Section 2270.002, Government Code, (a) This section applies only to a contract that: (1) is between a governmental entity and a company with 10 or more full-time employees; and (2) has a value of $100,000 or more that is to be paid wholly or partly from public funds of the governmental entity. (b)A governmental entity may not enter into a contract with a company for goods or services unless the contract contains a written verification from the company that it: (1) does not boycott Israel; and (2) will not boycott Israel during the term of the contract. 2.14 SB 252 prohibits the City from entering into a contract with a vendor that is identified by The Comptroller as a company known to have contracts with or provide supplies or service with Iran, Sudan or a foreign terrorist organization. -----INTENTIONALLY LEFT BLANK----- IN WITNESS WHEREOF, the parties hereto have caused this Contract to be executed the day and year first above written. Executed in triplicate. CITY OF LU OCK CONT OR BY: CL Daniel M. Pope, Mayor Authorized Repres ative ATTEST: Qvylca�t- aQQ Print Name Rebe ca Garza, City Sec etas lO/� �• /r�QC� L�� Address APPRO0 VED AS TO CONTENT: F City, State, Zip Code Robert Keinast, Deputy Chi f APPROVED A} T John Gra , 'st VC orney Exhibit A City of Lubbock,TX RFP 20-14921-SG Annual Firefighter Medical Physicals and Wellness Exams GENERAL REQUIREMENTS 1. INTENT a) The City of Lubbock (hereinafter called "City") is seeking proposals from interested firms and individuals, (hereinafter called "Provider") to provide Annual Firefighter Medical Physicals and Wellness Exams. b) Providers are invited to submit demonstrated competence and qualifications of their firm for providing these services. c) The information contained within this document is intended to provide interested firms with the requirements and criteria that will be used to make the selection. 2. SCOPE OF WORK Lubbock Fire Rescue is seeking to administer a health and wellness program that will deliver a quality health evaluation and wellness assessment to ensure the health and well-being of personnel as well as provide prevention and early detection of disease 1 illness. In order to implement this program, LFR is seeking a firm that will carry out a comprehensive medical exam that includes a health risk assessment and a complete medical history review to determine any health conditions that would prevent or could be aggravated by personnel performing their duties. The medical history shall also include any significant changes, job related exposures and new symptoms since the previous medical evaluation. Vendor must commit to delivering the services noted below with appropriately trained and qualified personnel (Nurse Practitioner or other approved heath care provider) and by a Medical Review Officer (MRO) PHYSICIAN/MEDICAL DOCTOR for Secondary Review for all "sworn civil service personnel". Services provided under items 2 through 5 below must be performed onsite at Lubbock Fire Rescue Administration located at 1515 East Ursuline, Lubbock Texas 79403. 1. Laboratory analysis must include: (must take place prior to physicals and reviewed during physicals): • Hemoccult Test • Urinalysis • Lipid Panel • Diabetes Tests (Hemoglobin Alc and Glucose) • Complete Blood Count • Comprehensive Metabolic Panel • Thyroid Panel • PSA(Men) • CA-125 (Women) • Heavy metal urine (For Hazmat/ Dive Members only- approx. 73 personnel) • Chlolinesterase—(For-Hazmat/Dive Members only- approx. 73 personnel) Laboratory analysis should be completed in such a way for the results to be reviewed with the individual at the time of the exam. If multiple trips are involved, this should be identified in the proposal for scheduling purposes. 2. Comprehensive medical exam(NFPA 1582 Compliant) to include: • Vision Exam (Titmus) • Personal Consultation with review of testing results • Behavioral Health/Trauma Screening • Occupational Hearing Exam • Skin cancer screening 3. Cardiopulmonary evaluation to include: • Echcardiograrm(Heart Ultrasound) • Resting EKG • Cardiac treadmill stress test with EKG • Carotid arteries (Ultrasound) • Aortic Aneurysm(Ultrasound) • Pulmonary function test • Aorta and aortic valve 4. Cancer and Disease Assessment to include: • Thyroid (Ultrsound) • Internal organs—liver,pancreas, gall bladder, kidneys and spleen (Ultrasound) • Bladder(Ultrasound) • Testicular and prostate for Men(Ultrasound) • Pelvic Ultrasound for Women(external) 5. Fitness Analysis (NFPA 1583 —WFI Guidelines): • Muscular Strength and Endurance Evaluation • Aerobic Endurance Evaluation(V02 Max Calc.) • Flexibility Evaluation • Nutrition and Diet Recommendations • Personal Fitness Recommendations • Metabolic analysis with body fat 6. Medical Clearances: • OSHA Respirator Medical Clearance Written medical clearance issued to LFR for each individual to perform emergency response services in compliance with National Fire Protection Association (NFPA) standard 1582. LFR Administration will require notification within 24 lirs. of any employee found not fit for duty. • Firefighter Medical Clearance NFPA 1582 as needed o Position with the company and work location o Years with the company o Education, Licenses and certifications o Work experience related to purpose on contact Proposals shall outline proven practices and procedures that will be used to perform the services: • Assurance of Primary Health Care Provider qualification • Plan detail of evaluation activities including confidentiality of records • Plan for maintaining written documentation regarding follow-up/referral program or procedures(s) reeonumendations • Provide a separate document signed by the official representative of the provider of assurance that confidentiality requirements are acknowledged and shall be met. The proposal should identify four current, major clients, particularly other fire department and / or governmental entities. Utilizing the Reference Form provided, include contact names and telephone numbers, indicate how long your firm has provided occupational medical exam services to these clients and the approximate number and type of exams conducted in each organization. Must be able to provide on-site testing with qualified personnel capable of administering scheduled physicals and procedures outlined. Health care provider shall be board certified with experience .in occupational medicine health care to Fire Rescue, Police and EMS agencies with a minimum 5 years of experience. The sonographer's personnel shall be registered diagnostic medical sonographers. Vendor shall develop a detail staffing plan that ensures that an adequate number of full and or part-tune staffing is trained and available and must provide other qualified licensed professionals as needed. Written respiratory protection clearance issued to LFR for each individual to wear positive and negative pressure respiratory protection in compliance with OSHA respiratory protection standard, 29CFR1910.134. 7. Written recommendation(s)of medical intervention and behavioral modification changes as well as programs and training to lessen the chance of injury and illness presented to employee ONLY. 8. Medical assessments revealing conditions that dictate further testing or treatment will be presented to employee ONLY so that follow-up can be pursued with personal physician. 3. MINIMUM QUALIFICATIONS The vendor must satisfy the following mandatory minimum requirements in order to have their responses evaluated. By submitting a proposal, the vendor warrants and represents that each satisfies these requirements. Failure to meet these requirements will result in the response not being evaluated and being rejected as non-responsive. 4. REQUIREMENTS A cover letter should be included with the proposal submittal identifying one contact person by name, address, telephone number, fax number and email address who will be designated as customer service representative and briefly outline how the firm will meet the needs for conducting Annual Firefighter Medical Physicals/Wellness Exams for LFR. Proposals should include a historical summary of the firm's experience conducting Fire Service specific baseline medical evaluations and key business data about the organization. The Proposer will identify the staff(including any subcontractors) that will provide the services defined in in the RFP. • Medical Physicals / Wellness Exams may be determined by a Nurse Practioner or approved health care provider and by a Medical Review Officer (MRO) PHYSICIAN/MEDICAL DOCTOR for Secondary Review. Doctors of medicine or osteopathy should have completed residency training in an accredited medical training program and / or American Boards of Medical Specialties (ABMS) or American Osteopathic Association(AOA) Board certified • Identify a Project Manager as a primary contact available for communication for the duration of the contract and a consistent point of contact for scheduling exams and other work scope matters • For each member of the team, describe the role that she/he will serve. Indicate those members of the team who will work closely with LFR's point of contact. • Please indicate the members of your project team who are sub-contractors (if any) to your organization. Include the ratio of staff to subcontractors in your proposed project team • Provide a short resume for each of the key medical and management project staff members and medical providers as appendices. Resumes should be no longer than(1)page and should contain the following information about each project member: Exhibit B Best and Final Offer City of Lubbock,TX RFP 20-14921-SG Annual Firefighter Medical Physicals and Wellness Exams Proposal Price Sheet (To be completed and returned with Proposal) Cardiopulmonary evaluation to include: PRICING • Echcardiograin (Heart Ultrasound) • Resting EKG • Cardiac treadmill stress test with EKG • Carotid arteries (Ultrasound) • Aortic Aneurysm (Ultrasound) • Pulmonary function test • Aorta and aortic valve Cardiopulmonary evaluation as listed above per individual: 230.00 Cancer and Disease Assessment to include: • Thyroid(Ultrsound) • Internal organs—liver, pancreas, gall bladder, kidneys and spleen (Ultrasound} • Bladder(Ultrasound) • Testicular and prostate for Men (Ultrasound) • Pelvic Ultrasound for Women (external) Cancer and Disease Assessment as listed above per individual: $ 6 .00 Fitness Analysis(NFPA 158' - WFI Guidelines) Muscular Strength and Endurance Evaluation • Aerobic Endurance Evaluation (V02 Max Calc.) • Flexibility Evaluation • Nutrition and Diet Recommendations • Personal Fitness Recommendations • Metabolic analysis with body fat Fitness Analysis as listed above per individual: $ 3 .00 Best and Final Offer City of Lubbock,TX RFP 20-14921-SG Annual Firefighter Medical Physicals and Wellness Exams Proposal Price Sheet (To be completed and returned with Proposal) Laboratory analysis must include (must take place prior to physicals and reviewed during physicals): • Hemoccult Test • Urinalysis • Lipid Panel • Diabetes Tests(Hemoglobin A I c and Glucose) • Complete Blood Count • Comprehensive Metabolic Panel • Thyroid Panel • PSA (Men) • CA-125 (Women) "Heavy metal urine(For Hazmat/ Dive Members only-approx. 73 personnel) "Cholinesterase—(For Hazmat/ Dive Members only-approx. 73 personnel) Laboratory analysis should be completed in such a way for the results to be reviewed and with the individual at the time ofthe exam. If multiple trips are involved,this should be identified in the proposal for scheduling purposes. PRICING Laboratory analysis as listed above per head packaged cost excluding $ 90.00 last two lines demarked with asterisk Laboratory analysis as listed above per head packaged cost including last two lines demarked with asterisk(Approx. 73 Hazmat/ Dive members) $ 152.00 Comprehensive medical exam (NFPA 1582 Compliant) to include: • Vision Exam (Titmus) • Personal Consultation with review of testing results) • Behavioral Health/Trauma Screening • Occupational Hearing Exam • Skin cancer screening Comprehensive medical exam as listed above per individual: S 90.00 Best and Final Offer City of Lubbock,TX RFP 20-14921-SG Annual Firefighter Medical Physicals and Wellness Exams Proposal Price Sheet (To be completed and returned with Proposal) Medical Clearances to include: PRICING •. OSHA Respirator Medical Clearance Written medical clearance issued to LFR for each individual to perform emergency response services in compliance with National Fire Protection Association (NEPA) standard 1582. LFR Administration will require notification within 24 hrs. of any employee found not fit for duty. • Firefighter Medical Clearance NFPA 1582 as needed Written respiratory protection clearance issued to LFR for each individual to wear positive and negative pressure respiratory protection in compliance with OSHA respiratory protection standard, 29CFR 1910.134. Medical Clearances as listed above per individual: 5 Overall Per Head Packaged Cost for ALL listed items above: $ 662.00 Services for optional tests/screening may be proposed with costs based on expertise and experience of the vendor. Vendor may attach a sheet to this Bid Sheet outlining the services and costs. Any additional services not specifically addressed in the RFP or the Proposers response shall be negotiated and agreed upon prior to entering into any contract Patricia�a11ns �, CEQ� Date: C' G" Exhibit C City of Lubbock, TX RFP 20-14421-SG Annual Firefighter Medical Physicals and Wellness Exams INSURANCE SECTION A. Prior to the approval of this contract by the City,the Contractor shall furnish a completed Insurance Certificate to the City, which shall be completed by an agent authorized to bind the named underwriter(s) to the coverages, limits, and termination provisions shown thereon, and which shall furnish and contain all required information referenced or indicated thereon. TIIE CITY SHALL HAVE NO DUTY TO PAY OR PERFORM UNDER THIS CONTRACT UNTIL SUCII CERTIFICATE SHALL HAVE BEEN DELIVERED TO THE CITY. INSURANCE COVERAGE REQUIRED SECTION B. The City reserves the right to review the insurance requirements of this section during the effective period of the contract and to require adjustment of insurance coverages and their limits when deemed necessary and prudent by the City based upon changes in statutory law,court decisions,or the claims history of the industry as well as the Contractor. SECTION C. The Contractor shall obtain and maintain in full force and effect for the duration of this contract,and any extension hereof,at Contractor's sole expense, insurance coverage written by companies approved by the State of Texas and acceptable to the City, in the following type(s)and amount(s): TYPE OF INSURANCE. COMBINED SINGLE LIMIT GENERAL LIABILITY ® Commercial General Liability ❑ Other General Aggregate $500.000 ❑ Claims Made ® Occurrence Products-Comp/Op AGG X ❑ W/Heavy Equipment Personal&Adv. Injury X ❑ To Include Products of Complete Operation Endorsements Contractual Liability X Fire Damage(Any one Fire) Med Exp(Any one Person) PROFESSIONAL LIABILITY ❑ General Aggregate $ AUTOMOTIVE LIABILITY ® Any Auto ❑ All Owned Autos Combined Single Limit ❑ Scheduled Autos ❑ Hired Autos Each Occurrence $500,000 ❑ Non-Owned Autos EXCESS LIABILITY ❑ Umbrella Fonn Each Occurrence Aggregate GARAGE LIABILITY ❑ Any Auto Auto Only-Each Accident ❑ Each Accident Aggregate ❑ BUILDER'S RISK ❑ 100%of the Total Contract Price ❑ INSTALLATION FLOATER ❑ 100%of the Total Material Costs ❑ POLLUTION ❑ CARGO ® WORKERS COMPENSATION—STATUTORY AMOUNTS OR OCCUPATIONAL MEDICAL AND DISABILITY ® EMPLOYERS'LIABILITY $500,000 OTHER:COPIES OF ENDOSEMENTS ARE REQUIRED ® City of Lzrbbock iinnrecl as aclditiotiai insured oii Auto/General Liability ori a priniai y mrd iron-coriti•iblrtory basis. ® To iiicliide pi•odircts ofconipleted operations eudorsenzeiit. ® YYaiver of subrogation iu favor of the City of Lubbock on all coverages,except The City of Lubbock shall be named as an additional insured on a primary and non-contributory basis and shall include waivers Of subrogation in favor of the City on all coverage's.Copies of the Certificates of Insurance and all applicable endorsements are required. ADDITIONAL POLICY ENDORSEMENTS The City shall be entitled, upon request,and without expense,to receive copies of the policies and all endorsements thereto and may make any reasonable request for deletion, revision, or modification of particular policy terms, conditions, limitations, or exclusions (except where policy provisions are established by law or regulation binding upon either of the parties hereto or the underwriter of any of such policies). Upon such request by the City,the Contractor shall exercise reasonable efforts to accomplish such changes in policy coverages,and shall pay the cost thereof. REQUIRED PROVISIONS The Contractor agrees that with respect to the above required insurance,all insurance contracts and certificate(s)of insurance will contain and state, in writing,on the certificate or its attachment, the following required provisions: a. Name the City of Lubbock and its officers,employees,and elected representatives as additional insureds,(as the interest of each insured may appear)as to all applicable coverage; b. Provide for thirty(30)days'notice to the City for cancellation,nonrenewal,or material change; c. Provide for notice to the City at the address shown below by registered mail; d. The Contractor agrees to waive subrogation against the City of Lubbock, its officers, employees, and elected representatives for injuries, including death, property damage, or any other loss to the extent same may be covered by the proceeds of insurance; e. Provide that all provisions of this contract concerning liability, duty, and standard of care together with the indemnification provision, shall be underwritten by contractual liability coverage sufficient to include such obligations within applicable policies. NOTICES The Contractor shall notify the City in the event of any change in coverage and shall give such notices not less than 30 days prior the change,which notice must be accompanied by a replacement CERTIFICATE OF INSURANCE. All notices shall be given to the City at the following address: Marta Alvarez,Director of Purchasing and Contract Management City of Lubbock 1625 1311'Street,Room 204 Lubbock,Texas 79401 SECTION D. Approval,disapproval,or failure to act by the City regarding any insurance supplied by the Contractor shall not relieve the Contractor of full responsibility or liability for damages and accidents as set forth in the contract documents. Neither shall the bankruptcy,insolvency,or denial of liability by the insurance company exonerate the Contractor from liability. CERTIFICATE OF INTERESTED PARTIES FORM 1295 10f1 Complete Nos.1-4 and 6 if there are interested parties. OFFICE USE ONLY Complete Nos.1,2,3,5,and 6 if there are no interested parties. CERTIFICATION OF FILING 1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number: of business. 2019-542880 Life Extension Clinics Inc. Lubbock,TX United States Date Filed: 2 Name of governmental entity or state agency that is a party to the contract for which the form is 09/21/2019 being filed. City of Lubbock Date Acknowledged: 10/21/2019 3 Provide the identification number used by the governmental entity or state agency to track or identify the contract,and provide a description of the services,goods,or other property to be provided under the contract. 20-14921-SG Annual Firefighter Medical Physicals 4 Nature of interest Name of Interested Party City,State,Country(place of business) (check applicable) Controlling Intermediary 5 Check only if there is NO Interested Party. ❑ X 6 UNSWORN DECLARATION My name is and my date of birth is My address is (street) (city) (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Executed in County, State of on the day of ,20 (month) (year) Signature of authorized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.3abaaf7d CERTIFICATE OF INTERESTED PARTIES FORM 1295 1 of 1 Complete Nos,1-4 and 6 if there are interested parties. OFFICE USE ONLY Complete Nos.1,2,3,5,and 6 if there are no interested parties. CERTIFICATION OF FILING 1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number: of business. 2019-542880 Life Extension Clinics Inc. Lubbock,TX United States Date Filed: 2 Name of governmental entity or state agency that is a party to the contract for which the form is 09/21/2019 being filed. City of Lubbock Date Acknowledged: g Provide the identification number used by the governmental entity or state agency to track or identify the contract,and provide a description of the services,goods,or other property to be provided under the contract. 20-14921-SG Annual Firefighter Medical Physicals 4 Nature of interest Name of Interested Party City,State,Country(place of business) (check applicable) Controlling Intermediary 5 Check only if there is NO Interested Party. ❑ X 6 UNSWORN DE 0N My name is ��� ®�{L��� and my date of birth is ` My address is :7a:AQ,-- � 0 trete (City)/ - (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Executed in—74611c 7 County, State of � on the 1—;bay o20 . (month) (year) Signature of author' agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.3a6aaf7d