00016025_4B-24_Mini-RFP_Attachment A_Final.docx

ATTACHMENT A – PROPOSAL COVER SHEET

Mini-RFP/ OregonBuys Bid Solicitation #: S-73000-00016025 [Transportation and Growth Management (“TGM”) File Code: 4B-24] Oregon Department of Transportation (“ODOT” or “Agency”)

Project Name: Wasco County Transportation System Plan (“TSP”) Update

Name of Firm:

Type name of primary contact for this Proposal:

Email address: Telephone:

MINIMUM REQUIREMENTS

[If any minimum requirements are listed in the Mini-RFP document (Section 2.4.7), Proposer must list here how they meet those requirements in the table below (add additional rows, if needed).]

PROPOSED SUBCONSULTANTS

[If required in the Mini-RFP document (Section 2.4.3), Proposer must list their proposed subconsultant firms and the discipline/type of work to be performed in the table below (add additional rows, if needed)]

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

1. Proposer has received copies of all addenda to this Mini-Solicitation.

2. 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 Mini-RFP; or b) any expenses incurred by Proposer in either preparing and submitting its Proposal, or in participating in the proposal evaluation/selection or Work Order Contract (“WOC”) negotiation process.

3. All contents of the Proposal, and this Mini-Solicitation Cover Sheet, are truthful and accurate.

4. Proposer has not and will not discriminate against a subcontractor in the awarding of a subcontract because the subcontractor is a minority, women or emerging small business enterprise certified under Oregon Revised Statute (“ORS”) 200.055.

5. If applicable, Proposer has, or will have prior to WOC 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.).

6. Proposer has no undisclosed liquidated and delinquent debt owed to the State or any department or agency of the State (Executive Order 17-09).

7. Proposer accepts all the terms and conditions contained in the Mini-RFP, and the referenced PA.

8. Proposer has made all required Conflict of Interest (“COI”) disclosures, if any, and (Check one of the following two certifications as applicable) |_| Proposer understands and has provided to all Associates (which includes subcontractors) the COI Guidelines and TGM COI Disclosure form (under Miscellaneous Procurement Forms, use “TGM 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. The response to each question on the TGM COI Disclosure form was “no”.

OR

|_| Proposer understands and has provided to all Associates (which includes subcontractors) the COI Guidelines and TGM COI Disclosure form (under Miscellaneous Procurement Forms, use “TGM 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 TGM COI Disclosure form(s) submitted as separate documents with this Proposal all disclosures required per the ODOT COI Guidelines.

9. 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

(Mini RFP Cover, ver. 7/01/21)