01_RFQ-25-401_Att_01_Contractor_Status_Form_ada.docx

ATTACHMENT 1

RFQ-25-401

CONTRACTOR STATUS FORM

This document provides the Energy Commission with basic information about the Firm and its key subcontractors. Each Firm must complete, sign, and include this attachment in its SOQ.

1. Firm Information Full Legal Name of Firm:

Business Address:

(street number and name)

E-mail:

2. Type of Entity or Business Organization Organization Tax ID Number: How long under current ownership?

Nature of Business Activity:

Number of employees: _________ Year established:

Legal form of organization (check one):

3. Small Business Preference Claim ***NOT APPLICABLE FOR RFQ*** Is your organization certified as a small business by the State of California, or have you applied for certification?

|_| No |_| Yes If yes, list your OSDS Number: _________________________ |_| Date certified:

|_| Application submitted to Office of Small Business Certification and Resources on:

(date) 4.

Disabled Veteran Business Participation Acknowledgement I certify that I have read and understand the requirements of DVBE participation and understand my obligations in regard to DVBE.

DVBE Incentive Participation |_| YES |_| NO DVBE Participation Amount must be documented on Attachment 4 Bidder Declaration.

5. Statement of Qualifications Contents Check to indicate the SOQ material you are submitting.

|_| Volume #1, Administrative Response |_| Volume #2, Technical Response

6. Handling Of CEC or Third-Party Confidential Information I certify that I have read and understand the confidentiality and security requirements for Confidential Information and Personal Information in Terms and Conditions located in Attachment 6 Standard Agreement Example. Only answer these questions for Firm and any other entity related to the agreement that will be given access to Confidential Information and/or Personal Information. Firm must answer the following questions yes or no.

Any “NO” answer means Firm will be screened out in Stage One Administrative and Completeness Screening and disqualified from further participation in the solicitation.

g) Does Firm have internal protocols for handling a security incident or data breach?

|_| YES |_| NO

7. Authorization and Certification I hereby authorize the California Energy Commission to make any inquiries necessary to verify the information I have presented in my Application.

I hereby authorize the California Energy Commission to obtain business credit reports and make any inquiries necessary to verify and evaluate the financial condition of the applicant.

I hereby certify that this application does not contain any confidential or proprietary information.

I hereby certify to the best of my knowledge and belief that I have read, understand, and do hereby accept the Terms and Conditions contained in this solicitation, including the provisions of the Agreement Terms and Conditions and, further, I am willing to enter into an agreement with the Commission to conduct the proposed project according to the Terms and Conditions without negotiation.

I hereby certify to the best of my knowledge, and under penalty of perjury, that the information contained in this Application is correct and complete.

I hereby certify that I am authorized to complete and sign this form on behalf of the applicant.

Signature of Authorized Representative Date

Typed Name Title

Evaluation Support