6166-0 Attachment C Proposer Information and Certification Sheet.pdf

RFP 6166 – Att C (OregonBuys Bid # S-44300-00014996)

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ATTACHMENT C — PROPOSER INFORMATION AND

CERTIFICATION SHEET

Legal Name of Proposer:

Address:

City, State, Zip:

Entity Type:

State of Incorporation:

Contact Name:

Telephone:

Email:

Oregon Business Registry Number (if required):

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

1. Proposer understands and accepts the requirements of this RFP. By submitting an Proposal, Proposer agrees to be bound by the Agreement terms and conditions in Attachment A and as modified by any Addenda, except for those terms and conditions that Agency has reserved for negotiation, as identified in the RFP.

2. Proposer acknowledges receipt of any and all Addenda to this RFP.

3. Proposal is a Firm Offer for 180 days following the Closing.

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

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 with regard to race, creed, age, religious affiliation, gender, disability, sexual orientation, national origin. When awarding sub-Agreements, 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 Agreement 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. Agency may not enter into an Agreement with an anticipated Agreement price of $150,000 or more with an 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.

Proposers continuing compliance constitutes a material element of this Agreement and a failure to comply constitutes a breach that entitles Agency to terminate this Agreement for cause.

Proposer may not prohibit any of Proposers 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.

8. 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 Agreement.

9. Proposer and Proposer’s employees, agents, and sub-Proposers 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/

10. 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, https://www.oregon.gov/DAS/Procurement/Pages/hb3060.aspx https://www.treasury.gov/ofac/downloads/sdnlist.pdf https://www.sam.gov/portal/

DAS Procurement Services, Version 4.0 – December 21, 2018 Page 3 of 5 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 RFP. If any changes occur with respect to Proposer’s status regarding conflict of interest, Proposer shall promptly notify the State in writing.

11. Proposer certifies that all contents of the Proposal (including any other forms or documentation, if required under this RFP) and this Proposal Certification Sheet , including the Minimum Qualifications Statement attached hereto* are truthful and accurate and have been prepared independently from all other Proposers, and without collusion, fraud, or other dishonesty.

12. Proposer understands that any statement or representation it makes, in response to this RFP, 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 Agreement 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.

13. Proposer acknowledges these certifications are in addition to any certifications required in the Agreement and Statement of Work in Attachment A at the time of Agreement execution.

Authorized Signature Date

(Printed Name and Title)

*Note: Proposer’s Minimum Qualification Statement appears on the following page.

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MINIMUM QUALIFICATIONS STATEMENT

Section 3.1 Minimum Qualifications of RFP 6166 states:

3.1 MINIMUM QUALIFICATIONS

To be considered for evaluation, Proposer must certify in the Statement of Minimum Qualifications attached to Attachment C: Proposer Information and Certification Sheet, that Proposer meet(s) the following requirements:

• Key Person Requirements

At least one of Proposer’s Key Persons must have a minimum of 2 years of experience in public finance, including state and federal financing for public and/or behavioral health.

At least one of Proposer’s Key Persons must have a minimum of 5 years’ experience in primary prevention efforts with respect to substance use and substance use disorder.

At least one of Proposer’s Key Persons must have experience in state or national needs assessment and systems analysis.

At least one of Proposer’s Key Persons must have some baseline knowledge or experience with services and systems related to evidence-based prevention of substance use, prevention science, or prevention practice in Oregon.

Does Proposer certify that Proposer meets the above Minimum Qualifications?

Instructions: provide Proposer’s response to the above question in the space below:

Proposer response:

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