6174-0 AttB Application and Applicant Certification Form final.docx

ATTACHMENT B - Application and Applicant Certification Form (Applicant, tab to each text box to enter information) Applicants Full and Legal Company Name:

Doing Business As (if applicable):

Address:

Applicant’s Contact Name:

Email Address:

Tax ID | FEIN | or SSN #:

Oregon Secretary of State (SOS) Is contractor currently registered with the SOS?

|_| Yes |_| No If yes, please provide Business Registry Number:

3.1 Minimum Qualifications. See Section 3.1 of RFQ.

3.1.1 Construction Contractors Board (CCB) License Summary.

Is Applicant actively registered with the CCB? |_| Yes |_| No CCB License number: Applicant must include a copy of this license with the Application Packet.

Date of issuance:

Year first licensed by CCB:

3.1.3 Building Codes Division (BCD) Plumbing and Electrical License Summary Does Applicant hold either of the following licenses issued by the BCD?

Plumbing License: |_| Yes |_| No License Status: Active |_| or inactive |_| License/Registration # Date of Issuance:

Electrical License: |_| Yes |_| No License Status: Active |_| or inactive |_| License/Registration # Date of Issuance:

3.1.4 Construction Contractors Board.

Within the past five years has Applicant had any:

Unpaid debt: Does Applicant currently have any unpaid claims or civil penalties?

|_| Yes |_| No Complaint history: Have any complaints been filed against Applicant with the CCB:

|_| Yes |_| No Disciplinary History: Has the Applicant had any civil penalties or other sanctions (license suspensions) issued by the CCB?

|_| Yes |_| No Administrative Suspensions: Has applicant ever been suspended by the CCB for the lack of bond/insurance? |_| Yes |_| No Year of suspension:

3.1.5 Does Applicant hold any of the following certifications?

Applicant must include copies of certifications with Application Packet.

Asbestos Abatement: |_| Yes |_| No Lead Paint: |_| Yes |_| No Other: if applicable

3.1.6 Good standing: Has Contractor held a contract that has been terminated or canceled by the Agency? |_| Yes |_| No NOTE: Agency will check Agency’s database.

If yes, what was the contract number found on page one of terminated or cancelled contract?

3.1.7 continued from above.

Check all counties Applicant is available to provide services in:

|_| Statewide (all 36 counties)

|_| Roofing

|_| General Construction Applicant, please list any other types of Environmental Modifications (construction services such as floor repairs, foundation repairs, etc.) your company offers:

3.1.9 Experience:

Number of years performing Environmental Modification services:

In which Oregon County?

5.2.3.a Insurance: Does Applicant currently have the type and limits of insurance required in Section 8. “Insurance” in Attachment A, Exhibit A, “Sample Environmental Contract”?

|_| Yes |_| No

APPLICANT, PLEASE ATTACH THE FOLLOWING DOCUMENTS IN THIS ORDER:

ATTACHMENT B - Application and Applicant Certification Form Continued

CERTIFICATION

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

1. Applicant understands and accepts the requirements of this RFQ. By applying, Applicant agrees to be bound by the contract terms and conditions in Attachment A “Sample Contract Form” and as modified by any Addenda, except for those terms and conditions that Agency has reserved for negotiation, as identified in the RFQ.

2. Applicant acknowledges receipt of any and all Addenda to this RFQ.

3. If awarded a contract, Applicant agrees to perform the scope of work / Statement of Work and meet the performance standards set forth in the final negotiated scope of work of the contract.

4. I have knowledge regarding Applicant’s payment of taxes and by signing below I hereby certify that, to the best of my knowledge, Applicant 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.

5. Applicant does not unlawfully discriminate in its employment practices with regard to race, creed, age, religious affiliation, gender, disability, sexual orientation, national origin. When awarding subcontracts, Applicant 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, Applicant 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. Agency may not enter into a contract with an anticipated contract price of $150,000 or more with a Applicant 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.

6. Applicant complies with ORS 652.220 and does not unlawfully discriminate against any of Applicant’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. Applicant’s continuing compliance constitutes a material element of resulting contract and a failure to comply constitutes a breach that entitles Agency to terminate any resulting contract for cause. Applicant may not prohibit any of Applicant’s employees from discussing the employee’s rate of wage, salary, benefits, or other compensation with another employee or another person. Applicant 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.

7. Applicant is not engaged in the provision of broadband Internet access service, or if at any time Applicant is engaged in or may engage in the provision of broadband Internet access service Applicant follows Oregon Laws 2018, Chapter 88 (HB 4155) and applicable Public Utility Commission rules, and will remain in compliance throughout the term of any resulting contract.

8. Applicant and Applicant’s employees, agents, and subcontractors are not included on:

9. Applicant certifies that, to the best of its knowledge, there exists no actual or potential conflict between the business or economic interests of Applicant, 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 Applicant’s status regarding conflict of interest, Applicant shall promptly notify the State in writing.

10. Applicant certifies that all contents of the Application Form (including any other forms or documentation, if required under this RFQ) are truthful and accurate and have been prepared independently from all other Applicants, Agency staff, and without collusion, fraud, or other dishonesty.

11. Applicant 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 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.

12. Applicant acknowledges these certifications are in addition to any certifications required in the contract and Statement of Work in Attachment A “Sample Trade Services Contract” at the time of contract execution.

13. Applicant agrees to comply with the federal terms and conditions in Exhibit D “Federal Terms and Conditions” of Attachment A “Sample Trade Services Contract.”

14. By signing and submitting this Application to the Agency, the Applicant attests that the Applicant has read and understands this RFQ and the Sample Contract.

Applicant Signature:

Authorized Signature Printed Name

Title Date

Attachment B Application Form Page 2 of 2