5523 RFQ Exhibit 2 Form.pdf

ODHS # 5523/LGE Opportunity Notice # S-10000-00004811 Page 9 of 10

EXHIBIT NO. 2

PROPOSER INFORMATION AND CERTIFICATION FORM

Legal Name of Proposer:________________________________________________________________ Address: ____________________________________________________________________________ City, State, Zip: _______________________________________________________________________ State of Incorporation: ___________________ Entity Type: ____________________________________ Contact Name:________________________________________________________________________ Telephone: ____________________________ Email: _________________________________________ Oregon Business Registry Number: ___________________________

Any individual signing below hereby certifies they are an authorized representative of proposer and that:

1. Proposer understands and accepts the requirements of this RFQ. By submitting a Quote, Proposer agrees to be bound by the Price Agreement and SOC terms and conditions, except for those terms and conditions if any that ODHS has reserved for negotiation, as identified in the RFQ.

2. Proposer acknowledges receipt of all Amendments to this RFQ.

3. Quote is a firm offer for 60 calendar days following the Bid Opening Date.

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

5. I have knowledge regarding Proposer’s payment of taxes and by signing 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 regarding 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 service-disabled 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. ODHS 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.

8. Proposer’s continuing compliance constitutes a material element of this SOC and a failure to comply constitutes a breach that entitles ODHS to terminate this SOC for cause.

https://www.oregon.gov/DAS/Procurement/Pages/hb3060.aspx

ODHS # 5523/LGE Opportunity Notice # S-10000-00004811 Page 10 of 10

9. Proposer may not prohibit any of Proposer’s employees from discussing the employee’s rate of wage, salary, benefits, or other compensation with another employee or another person. Proposer 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.

10. 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 SOC.

11. Proposer and Proposer’s employees, agents, and subcontractors 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://www.sam.gov/portal/

12. 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 RFQ. If any changes occur with respect to Proposer’s status regarding conflict of interest, Proposer shall promptly notify ODHS in writing.

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

14. Proposer understands that any statement or representation it makes, in response to this RFQ, 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 SOC 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.

15. Proposer acknowledges these certifications are in addition to any certifications required in the Price Agreement and the SOC at the time of SOC execution.

Authorized Signature: ____________________________________________ Date _________________

Printed Name and Title: ________________________________________________________________ https://www.treasury.gov/ofac/downloads/sdnlist.pdf https://www.sam.gov/portal/