ATTACHMENT C PROPOSAL COVER SHEET

RFP# S-73000-0014560 ; Oregon Department of Transportation

(Legal Name of Firm as provided to IRS) ______; a(an) __(enter State)____Corporation DBA Name (if different than legal name):___________________________________________ DUNS Number:____________

|_| Corporation |_| Professional Corporation |_| Ltd. Liability Company |_| Partnership |_| Limited Partnership |_| Ltd. Liability Partnership |_| Sole Proprietorship |_| Other __________ Mailing Address

Type name of primary Contact for this Proposal Email address Telephone Fax Type name of person(s) authorized to sign Contract/Price Agreement:

“PASS/FAIL” - PROPOSAL SUBMISSION CHECKLIST (for Proposer use)

“REQUIRED” ITEMS –

PROPOSAL SUBMISSION CHECKLIST (for Proposer use)

RESPONSES TO MINIMUM QUALIFICATIONS (See RFP Section 1.5.2)

· Registered Geotechnical Engineer Proposers must provide information below for at least one Registered Geotechnical Engineer intending to perform civil engineering services under the Contract/Price Agreement.

· Registered Engineering Geologist Proposers must provide information below for at least one PLS intending to perform surveying services under the Contract/Price Agreement.

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

1. Agency shall not be liable for: a) any claims or be subject to any defenses asserted by Proposer based upon, resulting from, or related to, Proposer's failure to comprehend all requirements of the RFP; or b) any expenses incurred by Proposer in either preparing and submitting its Proposal, or in participating in the proposal evaluation/selection or Contract/Price Agreement negotiation process, if any.

2. Neither the Proposer, a major partner or a major shareholder (defined as a partner or shareholder owning 10% or more of Proposer’s firm), a major subcontractor (defined as receiving 10% or more of the total Contract/Price Agreement amount), nor any principal officer of a Proposer, major partner, major shareholder or major subcontractor:

a) is presently debarred, suspended, disqualified, proposed for debarment or declared ineligible for the award of contracts by any federal agency or agency of the State of Oregon;

b) has an active exclusion on the System for Award Management (SAM) which is available at https://sam.gov/SAM/; or

c) has, within the last 3-year period, been convicted of or had a civil judgment rendered against them for: i) commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, state, or local) contract or subcontract; ii) violation of federal or state antitrust statutes relating to the submission of bids or Proposals; or iii) commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, or receiving stolen property.

{A "principal officer of a Proposer, major partner, major shareholder or major subcontractor," means an officer, director, owner, or partner and any person having primary management or supervisory responsibilities within a business entity (e.g., general manager; plant manager; head of a subsidiary, division, or business segment, and similar positions)}.

3. Proposer has made all required Conflict of Interest (COI) disclosures, if any.

The ODOT COI Guidelines and COI Disclosure Form are available at the following link: https://www.oregon.gov/ODOT/Business/Procurement/Pages/PSK.aspx (under “Miscellaneous Procurement Forms”) (Check one of the following two certifications as applicable) |_| Proposer understands and has provided to all Associates (which includes subcontractors) 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 (as defined in the COI Guidelines) 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 (which includes subcontractors) 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 (as defined in the COI Guidelines) have provided on the COI Disclosure Form(s) submitted with this Proposal all disclosures required per the ODOT COI Guidelines. Proposer shall incorporate in each required COI Disclosure Form any COI disclosure information provided by its staff, and attach COI Disclosure Forms from each of its subcontractors and any other Associates that have required disclosures per the ODOT COI Guidelines.

4. Proposer has available (and can furnish to Agency upon request) the appropriate financial, material, equipment, facility and personnel resources and expertise, or ability to obtain the resources and expertise, necessary to indicate the capability of the Proposer to meet all contractual responsibilities.

5. Proposer recognizes this is a public document open to public inspection. Any portion(s) of the Proposal that Proposer considers exempt from disclosure under Oregon Public Records Law is/are clearly designated in the Proposal and listed on a separate sheet attached to this Proposal Cover Sheet with justification and citation to the authority relied upon.

6. Proposer has not and will not discriminate in its employment practices with regard to race, creed, age, religious affiliation, sex, disability, sexual orientation or national origin. And, pursuant to ORS 279A.110, Proposer has not and will not discriminate against a subcontractor in the awarding of a subcontract because the subcontractor is a disadvantaged business enterprise, a minority-owned business, a woman-owned business, a business that a veteran owns or an emerging small business certified under ORS 200.055.

7. Proposer has an operating policy supporting equal employment opportunity.

8. 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, 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 additional information and sample policy template.)

9. The Proposal submitted is in response to the specific language contained in the RFP, and Proposer has made no assumptions based upon either (a) verbal or written statements not contained in the RFP, or (b) any previously-issued RFP, if any.

10. Proposer, acting through its authorized representative, has read and understands the RFP instructions, specifications, certifications and terms and conditions contained within the RFP (including the sample contract) and all Addenda, if any. Failure to provide information required by the RFP may ultimately result in rejection of the Proposal.

11. Proposer agrees to and shall comply with, all requirements, specifications, certifications and terms and conditions contained within the RFP (including the sample contract) and all Addenda, if any. (Note: Proposer must select “Yes” on Terms & Conditions tab in OregonBuys or the Proposal will be rejected).

12. Proposer and Proposer’s employees and agents are not included on the list entitled “Specially Designated Nationals and Blocked Persons” maintained by the Office of Foreign Assets Control of the United States Department of the Treasury and currently found at https://www.treasury.gov/resource-center/sanctions/SDN-List/Pages/default.aspx

13. All contents of the Proposal (including any other forms or documentation, if required under this RFP) and this Proposal Cover Sheet, are truthful and accurate and have been prepared independently from all other Proposers, and without collusion, fraud, or other dishonesty. False Claims: Proposer understands that any statement or representation it makes, in response to this solicitation, 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 the resulting PA/WOC being a "false claim" {ORS 180.750(2)} subject to the Oregon False Claims Act, ORS 180.750 to 180.785, or a false claim under the Federal False Claims Act, 31 U.S.C. Sections 3729 – 3733, or a violation of both Acts, and subject the Proposer to any liabilities or penalties associated with the making of a false claim under either Act.

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

[Note: Any alterations or erasures to the Proposal shall be initialed in ink by the above-named authorized representative.]

Proposal Cover Sheet (S014-B050523R1)