Application~1.docx

APPLICATION

for Maintenance Asphalt Price Agreement

Summary of Need: ODOT Maintenance forces purchase asphalt products (ACP, Asphalt Binder, Emulsified Asphalt Tack Coat) on an as-needed basis for projects performed by ODOT’s Maintenance crews. Generally, these purchases are made by ODOT picking up the asphalt products from a supplier’s plant. Occasionally, ODOT may ask that a supplier deliver the products.

Method of Procurement: In order to meet this need for asphalt products, ODOT enters into price agreements with multiple suppliers around the state. “Price agreement” is defined in ORS 279A.010 and means: a public contract for the procurement of goods or services as a set price with no guarantee of a minimum or maximum purchase. Price agreements for asphalt products are solicited using a special procurement method (SP-662-14) whereby a supplier submits an application and, if the supplier is determined by ODOT to be “responsible” as defined in ORS 279B.110 (See Section 1 for additional information), and their application is determined to be responsive, ODOT awards a price agreement to that supplier.

For purposes of complying with applicable aspects of ORS 279A and 279B regarding procurement of goods and services, an applicant for an asphalt price agreement is considered a “bidder” when that term is used in the statutes or related administrative rules. Once awarded a price agreement the applicant is referred to as “Contractor.”

TO APPLY:

1. Fill out sections 1, 2, and 3 completely.

a. Section 1 – Applicant Information and Qualifications: Fill in all required information and download and complete the Responsibility Inquiry form. If your company employs 50 or more full-time workers, you must also include a pay equity certificate as referenced in Section 10 of the Responsibility Inquiry form with your application.

b. Section 2 – Pricing: Enter pricing for all products you wish to offer under an awarded price agreement. Prices must remain in effect for at least the first 12 months of an awarded price agreement and are subject to monthly escalation/de-escalation. See the Sample Price Agreement, Section 4 for additional information on the escalation/de-escalation provisions and price change requests. (The Sample Price Agreement is filed in the OregonBuys Bid Solicitation attachments tab along with this Application.)

c. Section 3 - Certifications and Signature of Applicant’s Duly Authorized Representative. Make sure to check one of the Conflict of Interest checkboxes. At the bottom, either sign or use the checkbox certification – only one is required.

2. Be sure to carefully review the Sample Price Agreement as it contains terms and conditions (including insurance requirements and technical specifications) that you will be agreeing to by submitting an application. You will indicate your agreement with the terms, conditions, and specifications by choosing the “Yes” option on the Terms & Conditions tab in OregonBuys. If you select “Yes with exceptions” or “No,” your application will be rejected.

3. Submit your application through OregonBuys in response to Bid Solicitation number S-73000-00011918. Upload the application and other documents to the Attachments tab. Please confirm that the Items tab includes a check in the box marked “See quote attachment.”

4. If your application is accepted, ODOT will proceed with awarding a price agreement. Once the price agreement is executed, your price agreement will be in effect with an expiration date of December 31, 2034.

APPLICATION TABLE OF CONTENTS:

Section 1 – Applicant Information and Qualifications Section 2 – Pricing Section 3 – Certifications and Signature of Applicant’s Duly Authorized Representative

SECTION 1 – APPLICANT INFORMATION AND QUALIFICATIONS

Business Name:

Owner(s) Name:

Business Address:

· Contact person for matters relating to this application (prior to award of a price agreement):

Name: Phone:

Email:

· Applicant’s price agreement administrator:

This is the contact information that ODOT will use for all official notices and communications (other than placement of orders unless the same person is listed below) once a price agreement has been awarded

Name: Phone:

Email:

· Contact person for purchases by ODOT Maintenance under an awarded price agreement:

Name: Phone:

Email:

RESPONSIBILITY: ORS 279B.110 requires contracting agencies to determine whether a bidder or proposer (applicant in this case) for a public contract meets the following standards of responsibility:

· Has available the appropriate financial, material, equipment, facility and personnel resources and expertise necessary to meet all contractual responsibilities.

· Completed previous contracts of a similar nature with a satisfactory record of performance.

· Has a satisfactory record of integrity. Is legally qualified to contract with the contracting agency.

· Supplied all necessary information in connection with the inquiry concerning responsibility.

The information requested in this section is intended to assist ODOT in making its evaluation of responsibility. In addition, ODOT reserves the right to further investigate applicant’s responsibility using any available information and requesting additional information from the applicant if necessary. An applicant’s failure to provide information requested by ODOT in relation to the applicant’s responsibility may result in rejection of the application.

RESPONSIBILITY INQUIRY FORM: Submit with the application a completed, accurate, and signed Responsibility Inquiry form (including the pay equity certificate described in Item #10 if applicable). The Responsibility Inquiry form is available at:

https://www.oregon.gov/ODOT/Business/Procurement/DocsPSK/ResponsibilityInquiry.docx

EXPERIENCE: Provide a description of your company’s experience providing the products described in the Terms and Conditions and specifications. Include number of years and the types of products you provide. (Attach additional sheets if necessary):

REFERENCES: Provide below a list of three different customer references that can be contacted regarding the quality of products and services your company has provided within the past five years:

Reference #1 Customer Name (company name): ___________________________________________________ Products and/or services and dates provided:

Contact Person Name and Phone:

Reference #2 Customer Name (company name): ___________________________________________________ Products and/or services and dates provided:

Contact Person Name and Phone:

Reference #3 Customer Name (company name): ___________________________________________________ Products and/or services and dates provided:

Contact Person Name and Phone:

SECTION 2 – PRICING

Provide prices below for all products that your company will offer under a price agreement if one is awarded. You do not have to provide prices for all items in order to be considered for price agreement award. If there will be charges for minimum orders, starting up a plant in winter, etc., be sure to include those charges in the “Other Information” section. You must be clear about these items; for instance, for minimum orders – does that mean minimum picked up per day? Or for an entire order picked up over several days?

If you have more than one plant, submit a separate pricing page for each plant (make copies as needed). For each plant’s pricing, you must select the ODOT Maintenance District in which the plant is located. A map of ODOT districts is available online at:

https://www.oregon.gov/ODOT/Data/Documents/DistrictMaintMap.pdf

If you open an additional plant after a price agreement is awarded, it may be added to the price agreement via amendment. Contact ODOT’s price agreement administrator to add (or delete) locations.

Identification of the ODOT Maintenance District is for use in listing prices on a price list that is distributed to ODOT Maintenance personnel and posted on ODOT’s website. The identification of the district the plant is located in does not limit the supplier/contractor’s ability to make sales to any other ODOT district from that plant.

District (See District Map):

Plant Name and Location:

(Mar 15-Sept 30) Winter Price Per Ton (Oct 1 – Mar 14)

Other Information:

List and describe fully any minimum order restrictions or charges:

List and describe fully any start-up fees or winter closure information:

Anything else Maintenance personnel will need to know when ordering from your plant?

SECTION 3 – CERTIFICATIONS AND SIGNATURE OF APPLICANT’S DULY AUTHORIZED REPRESENTATIVE

As the authorized representative named below, I certify on behalf of the applicant that:

1. If awarded a price agreement, the applicant accepts and agrees to meet the performance standards set forth in the final price agreement and shall comply with all requirements and specifications in the application and sample price agreement . (Note: Applicant must select “Yes” on Terms & Conditions tab in OregonBuys or the application will be rejected).

2. If the applicant is awarded a price agreement, all pricing submitted in the application will be effective for a minimum of one year.

3. All contents of the application are truthful and accurate.

4. In accordance with ORS 279A.110(4), the applicant does not discriminate in its employment practices with regard to race, creed, age, religious affiliation, sex, disability, sexual orientation or national origin. And, pursuant to ORS 279A.110, the applicant has not and will not discriminate against a subcontractor in the awarding of a subcontract because the subcontractor is a disadvantaged business enterprise, a minority-owned business, a woman-owned business, a business that a veteran owns or an emerging small business certified under ORS 200.055.

5. The applicant has an operating policy supporting equal employment opportunity.

6. Neither the applicant, a major partner (defined as a partner or shareholder owning 10% or more of applicant’s firm) or a major subcontractor (defined as receiving 10% or more of the total sales made under the price agreement), nor any principal officer of an applicant, major partner, 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;

b) has an active exclusion on the System for Award Management (SAM) which is available at https://sam.gov/; or

c) has, within the last 3-year period, been convicted of or had a civil judgment rendered against them for: i) 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; ii) violation of federal or state antitrust statutes relating to the submission of bids or Proposals; or iii) 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, major shareholder 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)}

7. The applicant has reviewed and agrees to comply with ODOT’s Conflict of Interest (COI) Guidelines has made any required disclosures. if any, and:

(Check one of the following two certifications as applicable) |_| The applicant and (to the best of the below-named authorized representative’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 two-year period, and have no COI or other disclosures required per the COI Guidelines. The response to each question on the COI Disclosure Form was “no”.

|_| Applicant and (to the best of the below-named authorized representative’s information, knowledge and belief) all Associates (as defined in the COI Guidelines) have provided on the COI Disclosure Form(s) submitted with this Proposal all disclosures required per the ODOT COI Guidelines.

(The ODOT COI Guidelines and COI Disclosure Form are available at the following link: https://www.oregon.gov/ODOT/Business/Procurement/Pages/PSK.aspx (under “Guidance, Policy & Resources”)

8. Applicant is an independent contractor as defined in ORS 670.600 and as described in IRS Publication 1779, which is available at the following link: https://www.irs.gov/pub/irs-pdf/p1779.pdf.

9. Under penalty of perjury, the Applicant is, to the best of the below-named authorized representative’s knowledge, not in violation of any tax laws for taxes 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 local taxes administered by the Department of Revenue under ORS 305.620. [Ref ORS 305.385(6)]

10. 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, 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 Proposer that does not certify it has such a policy and practice. See additional information and sample policy template.)

AUTHORIZED SIGNATURE – CHOOSE OPTION 1 OR 2 BELOW

· OPTION 1 – Sign below in ink before scanning document or insert digital signature:

Authorized Representative Name:

Authorized Representative’s Title:

Authorized Signature: Date:

· OPTION 2 – Complete the boxes below:

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 and to submit the Application on behalf of Applicant.

Title Date xx/xx/xxxx

9/30/2024 image1.wmf oleObject1.bin