35613 RFA_Attachment_A_Application Cover Sheet_Final.doc

RFA# S-73000-00009423 - ATTACHMENT A

- APPLICATION COVER SHEET

Legal Name of Firm:_________________________________________________________________ DBA Name (if different than legal name):__________________________________________________

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Corporation FORMCHECKBOX Professional Corporation FORMCHECKBOX Ltd. Liability Company FORMCHECKBOX Partnership

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Limited Partnership FORMCHECKBOX Ltd. Liability Partnership FORMCHECKBOX Sole Proprietorship FORMCHECKBOX Other __________

Mailing Address

Type name of primary Contact for this Application:________________________________________ Email address ______________________________________________________________________ Telephone _________________________ Fax ________________________________ Type name of person(s) authorized to sign Contract: _____________________________________ “PASS/FAIL” Items - Application Submission Checklist (for Applicant use)

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Application Does Not Include Conditional Language about Terms and Conditions

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Meets Minimum Qualifications (See RFA Section 2.3)

“REQUIRED” Items – Application Submission Items Checklist* *Any checklists that may be contained in this RFA are provided only as a courtesy to prospective Applicant. Agency makes no representation as to the completeness or accuracy of any Checklist. Prospective Applicant is solely responsible for reviewing and understanding the RFA and complying with all the requirements of this RFA, whether listed in a checklist or not. Neither the State nor Agency is liable for any claims, or subject to any defenses, asserted by Applicant based upon, resulting from, or related to, Applicant’s failure to comprehend all requirements of this RFA.

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Application Cover Sheet with authorized signature

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Application submitted in OregonBuys

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Tax Compliance Affidavit (see RFA Attachment 3)

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Response to Minimum Qualifications (see RFA section 2.3)

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Copy of EVR Account Holder Agreement submitted

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Training Plan (see RFA section 3.6)

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Example of class materials used in previous EVR Training Programs (see RFA section 3.6)

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Marketing Plan (see RFA section 3.5)

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Inventory Plan (see RFA section 3.10)

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References included below (see RFA section 3.9)

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Subcontractor List (see RFA section 3.3)

Provide at least three references with telephone numbers (please verify numbers):

REFERENCE No. 1:

Organization Name:

Their Contact Person:

Project Title:

Telephone:

Fax:

Email:

REFERENCE No. 2:

REFERENCE No. 3:

CERTIFICATIONS. By signature below, the undersigned Authorized Representative on behalf of Applicant certifies that:

1.

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

2.

Neither the Applicant, a major partner or a major shareholder (defined as a partner or shareholder owning 10% or more of your firm), a major subcontractor, nor any principal officer of an Applicant, major partner, a major shareholder or major subcontractor:

a) is 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 does not have an Active Exclusion on the System for Award Management (SAM) which is available at http://sam.gov.

b) has, within the last 3-year period, been convicted of or had a civil judgment rendered against them for 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; violation of federal or state antitrust statutes relating to the submission of bids or Applications; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, or receiving stolen property? {A "principal officer of an Applicant, major partner 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.

Applicant 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: http://www.oregon.gov/ODOT/CS/OPO/AE.shtml#Forms (under “Misc. Procurement Related Forms”)

Check one of the following two certifications as applicable:

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Applicant understands and has provided to all Associates (which includes subcontractors) the COI Guidelines and COI Disclosure Form. Applicant and, to the best of the undersigned’s information, knowledge and belief, Applicant’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 one-year period, and have no conflicts of interest or other disclosures required per the COI Guidelines or COI Disclosure Form.

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Applicant understands and has provided to all Associates (which includes subcontractors) the COI Guidelines and COI Disclosure Form. Applicant and, to the best of the undersigned’s information, knowledge and belief, all Associates (as defined in the COI Guidelines) have provided on the COI Disclosure Form(s) submitted with this Application all disclosures required per the ODOT COI Guidelines.

4.

Applicant 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 Applicant to meet all contractual responsibilities.

5.

All Applications are public records and are subject to public inspection after Agency issues the Notice of the Intent to Award. Application of the Oregon Public Records Law will determine whether any information is exempt from disclosure.

All Applications submitted in response to this RFA become the Property of Agency. By submitting an Application in response to this RFA, Applicant grants the State a non-exclusive, perpetual, irrevocable, royalty-free license for the rights to copy, distribute, display, prepare derivative works of and transmit the Application solely for the purpose of evaluating the Application, negotiating a Contract, if awarded to Applicant, or as otherwise needed to administer the RFA process, and to fulfill obligations under Oregon Public Records Law (ORS 192.311 through 192.478). Applications, including supporting materials, will not be returned to Applicant, except in the case of Applications that were submitted late and rejected by Agency.

If Applicant believes any of its Application is exempt from disclosure under Oregon Public Records Law (ORS 192.311 through 192.478), Applicant shall submit a completed and signed Disclosure Exemption Certification (Attachment 4) and a fully redacted version of its Application, clearly identified as the redacted version.

6.

Applicant does not discriminate in its employment practices with regard to race, creed, age, religious affiliation, sex, disability, sexual orientation or national origin. Nor has Applicant or will Applicant discriminate against a subcontractor in the awarding of a subcontract because the subcontractor is:

· a minority, women or emerging small business enterprise certified under ORS 200.055, or

· a business enterprise that is owned or controlled by or that employs a disabled veteran, as defined in ORS 408.225.

7.

Applicant has an operating policy supporting equal employment opportunity. If proposing firm has 50 or more people, Applicant also has a formal equal opportunity program.

· Does Applicant have 50 or more employees? FORMCHECKBOX Yes, FORMCHECKBOX No.

· Does Applicant have a formal equal employment opportunity program? FORMCHECKBOX Yes, FORMCHECKBOX No

Agency is an equal-employment-opportunity employer and values diversity in its work force. Agency requires Integrators to have an operating policy as an equal employment opportunity employer. Firms of 50 people or less do not need to have a formal equal employment opportunity program, but shall have an operating policy supporting equal employment opportunity. Firms of 50 people or more shall also have a formal equal employment opportunity program.

8.

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

9.

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

10.

If awarded a Contract, Applicant agrees to perform the scope of work and meet the performance standards set forth in the final negotiated scope of work of the Contract, and shall comply with, all requirements, specifications and terms and conditions contained within the RFA (including the sample contract) and all Addenda, if any.

11.

Applicant and Applicant’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 http://www.treas.gov/offices/enforcement/ofac/sdn/t11sdn.pdf.

12.

Information and prices included in this Application shall remain valid for 180 days after the Application due date unless this period is extended by mutual agreement.

13.

All contents of the Application (including any other forms or documentation, if required under this RFA) and this Application Cover Sheet are truthful and accurate and have been prepared independently from all other Applicants, and without collusion, fraud, or other dishonesty. False Claims. Applicant 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 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.

14.

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

Title

Date xx/xx/xxxx

Attachment A Cover Sheet