00013619_AttC~1.doc

RFP [73000-00013619] – [Audiometric Services] Att C

ATTACHMENT C — PROPOSER INFORMATION AND CERTIFICATION SHEET

Legal Name of Proposer:

Address:

City, State, Zip:

State of Incorporation:

Entity Type:

Contact Name:

Telephone:

Email:

Oregon Business Registry Number (if required):

As the authorized representative named below, I certify on behalf of Proposer that:

1. Proposer understands and accepts the requirements of this RFP. By submitting a Proposal, Proposer agrees to be bound by the Contract terms and conditions in Attachment A and as modified by any Addenda, except for those terms and conditions that Agency has reserved for negotiation, as identified in the RFP.

2. Proposer acknowledges receipt of any and all Addenda to this RFP.

3. Proposal is a Firm Offer for 180 days following the Bid Opening Date identified in OregonBuys.

4. If awarded a Contract Proposer agrees to perform the scope of work and meet the performance standards set forth in the final negotiated scope of work of the Contract.

5. I have knowledge regarding Proposer’s payment of taxes and by checking the “APPROVED” checkbox and entering my name below I hereby certify that, to the best of my knowledge, Proposer is not in violation of any tax laws of the state or a political subdivision of the state, including, without limitation, ORS 305.620 and ORS chapters 316, 317 and 318.

6. Proposer does not discriminate in its employment practices with regard to race, creed, age, religious affiliation, gender, disability, sexual orientation, national origin. When awarding subcontracts, Proposer does not discriminate against any business certified under ORS 200.055 as a disadvantaged business enterprise, a minority-owned business, a woman-owned business, a business that a veteran owns or an emerging small business. If applicable, Proposer has, or will have prior to contract execution, a written policy and practice, that meets the requirements described in ORS 279A.112 (formerly HB 3060), of preventing sexual harassment, sexual assault and discrimination against employees who are members of a protected class. (Agency may not enter into a contract with an anticipated contract price of $150,000 or more with a Proposer that does not certify it has such a policy and practice. See https://www.oregon.gov/DAS/Procurement/Pages/hb3060.aspx for additional information and sample policy template.)

7. Proposer complies with ORS 652.220 and does not unlawfully discriminate against any of Proposer’s employees in the payment of wages or other compensation for work of comparable character on the basis of an employee’s membership in a protected class. “Protected class” means a group of persons distinguished by race, color, religion, sex, sexual orientation, national origin, marital status, veteran status, disability or age.

Contractor’s continuing compliance constitutes a material element of the Contract and a failure to comply constitutes a breach that entitles Agency to terminate the Contract for cause.

Contractor may not prohibit any of Contractor’s employees from discussing the employee’s rate of wage, salary, benefits, or other compensation with another employee or another person. Contractor may not retaliate against an employee who discusses the employee’s rate of wage, salary, benefits, or other compensation with another employee or another person.

8. Proposer is not engaged in the provision of broadband Internet access service, or if at any time Proposer is engaged in or may engage in the provision of broadband Internet access service, Proposer is in compliance with Oregon Laws 2018, Chapter 88 (HB 4155) and applicable Public Utility Commission rules, and will remain in compliance throughout the term of the Contract.

9. Proposer and Proposer’s employees, agents, and subcontractors are not presently debarred, suspended, proposed for debarment under ORS 279B.130, or declared ineligible for the award of contracts by any federal agency or agency of the State of Oregon and are not included on:

A. the “Specially Designated Nationals and Blocked Persons” list maintained by the Office of Foreign Assets Control of the United States Department of the Treasury found at: https://www.treasury.gov/ofac/downloads/sdnlist.pdf., or B. the government wide exclusions lists in the System for Award Management found at: https://sam.gov/SAM/

10. Proposer certifies that, to the best of its knowledge, there exists no actual or potential conflict between the business or economic interests of Proposer, its employees, or its agents, on the one hand, and the business or economic interests of the State, on the other hand, arising out of, or relating in any way to, the subject matter of the RFP. If any changes occur with respect to Proposer’s status regarding conflict of interest, Proposer shall promptly notify the State in writing. Proposer has made all Conflict of Interest (COI) disclosures, if any as required by the ODOT COI Guidelines and COI Disclosure Form available at the following link: https://www.oregon.gov/ODOT/Business/Procurement/Pages/PSK.aspx) (Check one of the following two certifications as applicable)

Proposer understands and has provided to all Associates (as defined in the COI Guidelines) the COI Guidelines and COI Disclosure Form. Proposer and, to the best of the below-named authorized representative’s information, knowledge and belief, Proposer’s Associates are in conformance with the COI Guidelines, have no employees that were employed by ODOT within the last two-year period, and have no conflicts of interest or other disclosures required per the COI Guidelines or COI Disclosure Form.

Proposer understands and has provided to all Associates (as defined in the COI Guidelines) the COI Guidelines and COI Disclosure Form. Proposer and, to the best of the below-named authorized representative’s information, knowledge and belief, all Associates have provided on the COI Disclosure Form(s) submitted with this Proposal all disclosures required per the ODOT COI Guidelines.

11. Proposer certifies that all contents of the Proposal (including any other forms or documentation, if required under this RFP) and this Proposal Certification Sheet, are truthful and accurate and have been prepared independently from all other Proposers, and without collusion, fraud, or other dishonesty.

12. Proposer understands that any statement or representation it makes, in response to this RFP, if determined to be false or fraudulent, a misrepresentation, or inaccurate because of the omission of material information could result in a "claim" {as defined by the Oregon False Claims Act, ORS 180.750(1)}, made under Contract being a "false claim" {ORS 180.750(2)} subject to the Oregon False Claims Act, ORS 180.750 to 180.785, and to any liabilities or penalties associated with the making of a false claim under that Act.

13. Proposer acknowledges these certifications are in addition to any certifications required in the Contract and Statement of Work in Attachment A at the time of Contract execution.

14. By entering my name and title below and checking the “APPROVED” checkbox, I certify I am an authorized representative of the Proposer, duly authorized to bind the Proposer and make all representations, attestations, and certifications contained in the Proposal document and to submit this Proposal document on behalf of Proposer.

Title

Date xx/xx/xxxx

PROPOSER INFORMATION AND CERTIFICATION SHEET – APPENDIX 1

REFERENCES

REFERENCES FOR COMPARABLE PROJECTS IN SIZE AND SCOPE: Provide 3 references from current or former client firms for similar projects performed within the last 4 years. References must be able to verify the quality of previous, related Work.

Name of Firm:

Reference Contact Person:

Alternate Reference Contact Person:

Project/Contract Title:

Description of Services/Goods provided:

Name of Firm:

Reference Contact Person:

Alternate Reference Contact Person:

Project/Contract Title:

Description of Services/Goods provided:

Name of Firm:

Reference Contact Person:

Alternate Reference Contact Person:

Project/Contract Title:

Description of Services/Goods provided:

Version 1.0 - November 19, 2014 Version 3.0 - (ODOT S015-G061021R1)