9198 ITB Attachment 1 CAF.pdf

ITB 9198 ATTACHMENT 1

9198 ITB Attachment 1 CAF.docx Page 1 of 2

CONTRACTUAL ACCEPTANCE FORM

BIDDER SHALL PROVIDE ALL APPLICABLE INFORMATION REQUESTED BELOW

THIS ATTACHMENT MUST BE COMPLETED AND RETURNED WITH BID

BIDDER’S LEGAL NAME: (TAX FILING) __________________________________________________________

BIDDER’S MAILING ADDRESS: ________________________________________________________________

BIDDER’S BUSINESS DESIGNATION: (CHECK ONE)

Partnership Limited Partnership Limited Liability Partnership

Corporation Professional Corporation Limited Liability Company

Sole Proprietorship Other: ____________________________________________

BIDDER’S FEDERAL TAX ID NUMBER: (NOT SOCIAL SECURITY NUMBER) _________________________

Tax information is requested pursuant to ORS 305.385 and will be used for the administration of state, federal and local tax laws. OPRD may report the information provided to the Internal Revenue Service (IRS) under the name and taxpayer identification number provided.

BIDDER’S OREGON BUSINESS REGISTRATION NUMBER: _________________________________

(OREGON SECRETARY OF STATE, CORPORATIONS DIVISION)

Go to http://www.filinginoregon.com/ for information on how to register to do business in Oregon.

BIDDER IS A RESIDENT BIDDER: YES NO

ORS 279A.120(1)(b): “Resident bidder” means a bidder that has paid unemployment taxes or income taxes in Oregon during the 12 calendar months immediately preceding submission of the bid, has a business address in Oregon and has stated in the bid whether the bidder is a “resident bidder” under this paragraph.

BIDDER IS AN OREGON CERTIFIED FIRM: (CHECK ALL THAT APPLY)

Minority Business Enterprise (MBE) Emerging Small Business (ESB)

Women Business Enterprise (WBE) Disadvantaged Business Enterprise (DBE)

Go to http://www.oregon4biz.com/Grow-Your-Business/Business-services/Minority-Owned-Business-Certification/ for information on the OMWESB certification program.

BIDDER’S CONTACT INFORMATION:

AUTHORIZED REPRESENTATIVE TITLE

PHONE FAX EMAIL

THE INDIVIDUAL SIGNING ON BEHALF OF BIDDER HEREBY ACKNOWLEDGES AND CERTIFIES THAT:

• He/she is authorized to act on behalf of Bidder,

• The supplied Contractor data is true and accurate,

• To the best of his/her knowledge, Bidder is not in violation of any Oregon tax laws, For the purposes of this certification, “Oregon Tax Laws” means a state tax imposed by ORS 320.005 to 320.150 and 403.200 to

403.250 and ORS chapters 118, 314, 316, 317, 318, 321 and 323 and the elderly rental assistance program under ORS 310.630 to

310.706 and local taxes administered by the Department of Revenue under ORS 305.620. [ORS 305.380(4)]

• Bidder has completely read and understands the provisions of the Solicitation, including any Addenda issued,

• The Bid was prepared independently from all other Bidders, and without collusion, fraud, or other dishonesty,

• Bidder has not discriminated and will not discriminate, in violation of ORS 279A.110(1), against any minority, women or emerging small business enterprise certified under ORS 200.055 or a business that is owned or controlled by or that employs a disabled veteran as defined in ORS 408.225 in obtaining any required subcontract,

• Bidder accepts and agrees to be bound by all the terms and conditions of the Contract awarded, http://www.oregon4biz.com/Grow-Your-Business/Business-services/Minority-Owned-Business-Certification/

ITB 9198 ATTACHMENT 1

9198 ITB Attachment 1 CAF.docx Page 2 of 2

• Bidder agrees to provide all Goods and Services required to be provided under the Contract,

• Bidder has the available resources, including staffing, to perform the Services in a reasonable timeframe to pursue OPRD’s objectives, and

• By submitting a response to this Solicitation, Bidder grants the State of Oregon a non-exclusive, perpetual, irrevocable, royalty-free, worldwide license for the rights to copy, distribute, display, prepare derivative works of and transmit the response for the purpose of conducting this procurement and to fulfill obligations under Oregon Public Records Laws.

SIGNATURE OF BIDDER’S AUTHORIZED REPRESENTATIVE DATE