ATT C Bidder's Certifications.docx

ATTACHMENT C- BIDDER CERTIFICATION

WAGE THEFT PREVENTION –

RESPONSIBLE BIDDER CRITERIA WASHINGTON STATE GOODS & SERVICES CONTRACTS

Prior to awarding a contract, agencies are required to determine that a bidder is a ‘responsible bidder.’ See RCW 39.26.160(2) & (4). Pursuant to legislative enactment in 2017, the responsible bidder criteria include a contractor certification that the contractor has not willfully violated Washington’s wage laws. See Chap. 258, 2017 Laws (enacting SSB 5301).

I hereby certify, on behalf of the firm identified below, as follows (check one):

OR

I hereby certify, under penalty of perjury under the laws of the State of Washington, that the certifications herein are true and correct and that I am authorized to make these certifications on behalf of the firm listed herein.

FIRM NAME:

Name of Contractor/Bidder – Print full legal entity name of firm

By:

Signature of authorized person

Print Name of person making certifications for firm

Title:

Place:

Title of person signing certificate

Print city and state where signed

Date:

ATTACHMENT C

EXECUTIVE ORDER 18-03 – WORKERS’ RIGHTS

WASHINGTON STATE GOODS & SERVICES CONTRACTS CERTIFICATION

Pursuant to the Washington State Governor’s Executive Order 18-03 (dated June 12, 2018), the Washington State Department of Health is seeking to contract with qualified entities and business owners who certify that their employees are not, as a condition of employment, subject to mandatory individual arbitration clauses and class or collective action waivers.

Solicitation No.: DOH#24-029C Care-a-Van Mobile Services I hereby certify, on behalf of the firm identified below, as follows (check one):

NO MANDATORY INDIVIDUAL ARBITRATION CLAUSES AND CLASS OR COLLECTIVE ACTION WAIVERS FOR EMPLOYEES. This firm does NOT require its employees, as a condition of employment, to sign or agree to mandatory individual arbitration clauses or class or collective action waivers.

OR

MANDATORY INDIVIDUAL ARBITRATION CLAUSES AND CLASS OR COLLECTIVE ACTION WAIVERS FOR EMPLOYEES. This firm requires its employees, as a condition of employment, to sign or agree to mandatory individual arbitration clauses or class or collective action waivers.

I hereby certify, under penalty of perjury under the laws of the State of Washington, that the certifications herein are true and correct and that I am authorized to make these certifications on behalf of the firm listed herein.

FIRM NAME: _____________________________________________________

Name of Contractor/Bidder – Print full legal entity name of firm.

By: ______________________________ Signature of authorized person Print Name of person making certifications for firm.

Date: ________________________________

ATTACHMENT C - BIDDER’S PROFILE

Bidder:

Type/print full legal name of Bidder

Bidder’s Address:

Type/print Bidder’s Address

Bidder Organization Type:

Check appropriate box

* Note: A sole proprietorship is an unincorporated business owned and run by an individual with no distinction between the business and the owner. It is not a legal entity. It simply refers to a person who owns the business and is personally responsible for its debts and who pays personal income taxes on profits earned from the business. If you are a bidder who operates a business on your own, you automatically are a sole proprietor unless you have adopted a business structure (e.g., corporation, LLC, partnership).

State of Formation for Corp./LLC/Partnership:

Type/print the state where the corporation, LLC, or partnership is formed – e.g., ‘Washington’ if domestic and the name of the state if ‘Foreign’ (i.e., not Washington)

Doing Business Under Another Name:

Check appropriate box State whether Bidder has been doing business under another name during the past five years:

If Bidder HAS done business under another name, provide the name(s) and addresses:

Name: ___________________________________ Address: ___________________________________

Bidder, through the duly authorized undersigned, makes this certification as a required element of submitting a responsive bid. Bidder certifies, to the best of its knowledge and belief, that the following are true, complete, correct, and made in good faith:

1. UNDERSTANDING. Bidder certifies that Bidder has read, thoroughly examined, and fully understands all of the provisions in the Competitive Solicitation (including all Attachments) and the terms and conditions of the Contract and any amendments or clarifications to the Competitive Solicitation and agrees to abide by the same.

2. ACCURACY. Bidder certifies that Bidder has carefully prepared and reviewed its bid and fully supports the accuracy of the same. Bidder further understands and acknowledges that DOH shall not be responsible for any errors or omissions on the part of Bidder in preparing its bid. The bidder certifies that the facts declared here are true and accurate. Bidder further understands and acknowledges that the continuing compliance with these statements and all requirements of the Competitive Solicitation are conditions precedent to the award or continuation of the resulting Contract.

3. NO COLLUSION OR ANTI-COMPETITIVE PRACTICES. Bidder certifies that Bidder has not, either directly or indirectly, entered into any agreement, participated in any collusion, or otherwise taken any action in restraint of free competitive bidding in connection with this Competitive Solicitation. Bidder certifies that Bidder’s bid prices have been arrived at independently, without engaging in collusion, bid rigging, or any other illegal activity, and without for the purpose of restricting competition any consultation, communication, or agreement with any other bidder or competitor relating to (a) those prices, (b) the intention to submit a bid, or (c) the methods or factors used to calculate the prices offered. Bidder certifies that Bidder has not been and will not knowingly disclose its bid prices, directly or indirectly, to any other bidder or competitor before award of a Contract, unless otherwise required by law. Bidder certifies that Bidder has made no attempt and shall not make any attempt to induce any other person or firm to submit or not to submit a bid for the purpose of restricting competition. Bidder, however, freely may join with other persons or organizations for the purpose of presenting a bid.

4. FIRM OFFER. Bidder certifies that its bid, attached hereto, is a firm offer which cannot be withdrawn for a period of ninety (90) days from and after the bid due date specified in the Competitive Solicitation. DOH may accept such bid, with or without further negotiation, at any time within such period. In the event of a protest, Bidder’s bid shall remain valid for such period or until the protest and any related court action is resolved, whichever is later.

5. CONFLICT OF INTEREST. Bidder certifies that, in preparing this bid, Bidder has not been assisted by any current or former employee of the State of Washington whose duties relate (or did relate) to this Competitive Solicitation, or prospective Contract, and who was assisting in other than his or her official, public capacity. Neither does such a person nor any member of his or her immediate family have any financial interest in the outcome of this bid.

6. NO REIMBURSEMENT. Bidder certifies that Bidder understands that the State of Washington will not reimburse Bidder for any costs incurred in the preparation of this bid. All bids become the property of the State of Washington, and Bidder claims no proprietary right to the ideas, writings, items, or samples unless so stated in the bid.

7. PERFORMANCE. The Bidder certifies that Bidder understands that its submittal of a bid and execution of this Bidder’s Certification certifies Bidder’s willingness to comply with the Contract, if awarded such. By submitting this bid, Bidder hereby offers to furnish the goods and/or services solicited pursuant to this Competitive Solicitation in compliance with all terms, conditions, and performance requirements contained in this Competitive Solicitation and the resulting Contract or, if applicable, as detailed on a Contract Issues List, if permitted, in this Competitive Solicitation.

8. INSURANCE. Bidder certifies as follows (must check one):

· BIDDER HAS REQUIRED INSURANCE. Bidder has attached a current, valid Certificate of Insurance for each and all of the required insurance coverages as specified in the Contract (note: Bidder must attach the Insurance Certificate).

OR

· BIDDER WILL OBTAIN REQUIRED INSURANCE. Bidder does not have a current, valid Certificate of Insurance for each and all of the required insurance coverages as specified in the Contract but, if designated as the Apparent Successful Bidder, Bidder will provide such a Certificate of Insurance, without exception of any kind, to DOH within twenty-four (24) hours of such designation or notification by DOH or be deemed a nonresponsive bid.

OR

· BIDDER DOES NOT HAVE REQUIRED INSURANCE. As detailed on the attached explanation (Bidder to provide), Bidder does not have a current, valid Certificate of Insurance for each and all of the required insurance coverages as specified in the Contract and, if designated as the Apparent Successful Bidder would not be able to provide such a Certificate of Insurance to DOH within twenty-four (24) hours of such designation.

9. DEBARMENT. Bidder certifies as follows (must check one):

· NO DEBARMENT. Bidder and/or its principals are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from contracting with any federal, state, or local governmental entity.

OR

· DEBARRED. As detailed on the attached explanation (Bidder to provide), Bidder and/or its principals presently are debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from contracting with a federal, state, or local governmental entity.

10. CRIMINAL OFFENSE. Bidder certifies as follows (must check one):

· NO CRIMINAL OFFENSE. Bidder and its officers, directors, and managers have not, within the three (3) year period preceding the date of this Competitive Solicitation, been convicted or had a civil judgment rendered against Bidder or such officers, directors, and managers for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a governmental contract; violation of any federal or state antitrust statute; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property. Bidder further certifies that Bidder and its officers, directors, and managers are not presently indicted or otherwise criminally or civilly charged by a governmental entity with commission of any of the offenses enumerated in this paragraph.

OR

· CRIMINAL OFFENSE. As detailed on the attached explanation (Bidder to provide), within the three (3) year period preceding the date of this Competitive Solicitation, Bidder or its officers, directors, or managers have been convicted or had a civil judgment rendered against Bidder or such officers, directors, or managers for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a governmental contract; violation of any federal or state antitrust statute; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property.

11. WAGE THEFT PREVENTION. Bidder certifies as follows (must check one):

· NO WAGE VIOLATIONS. Bidder has NOT been determined by a final and binding citation and notice of assessment issued by the Washington Department of Labor and Industries or through a civil judgment entered by a court of limited or general jurisdiction to have willfully violated, as defined in RCW 49.48.082, any provision of RCW 49.46, RCW 9.48, or RCW 49.52 within three (3) years prior to the date of the above-referenced Competitive Solicitation date.

OR

· VIOLATIONS OF WAGE LAWS. Bidder has been determined by a final and binding citation and notice of assessment issued by the Washington Department of Labor and Industries or through a civil judgment entered by a court of limited or general jurisdiction to have willfully violated, as defined in RCW 49.48.082, a provision of RCW 49.46, RCW 49.48, or RCW 49.52 within three (3) years prior to the date of the above-referenced Competitive Solicitation date.

12. CIVIL RIGHTS. Bidder certifies as follows (must check one):

· COMPLIANCE WITH CIVIL RIGHTS REQUIREMENTS. Bidder complies with all applicable requirements regarding civil rights. Such requirements prohibit discrimination against individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on their race, color, religion, sex, sexual orientation, gender identity, or national origin.

OR

· NON-COMPLIANCE WITH CIVIL RIGHTS REQUIREMENTS. Bidder does not comply with all applicable requirements regarding civil rights.

13. STATUTORY NONDISCRIMINATION CLAUSES FOR STATE CONTRACTS. Bidder certifies as follows (must check one):

☐ COMPLIANCE WITH STATUTORY NONDISCRIMINATION CLAUSES FOR STATE CONTRACTS. During the term of an awarded Contract, Bidder, including any subcontractor, shall not discriminate on the bases enumerated at RCW 49.60.530(3). Bidder, including any subcontractor, also shall give written notice of this nondiscrimination requirement to any labor organizations with which Bidder, or subcontractor, has a collective bargaining or other agreement. In addition, Bidder, including any subcontractor, shall cooperate with any Washington state agency investigation regarding any allegation that Bidder, including any subcontractor, engaged in prohibited discrimination set forth in RCW 49.60.530(3).

OR

☐ NON-COMPLIANCE WITH STATUTORY NONDISCRIMINATION CLAUSES FOR STATE CONTRACTS. Bidder does not comply with RCW 49.60.530.

14. WORKERS’ RIGHTS (EXECUTIVE ORDER 18-03). Bidder certifies as follows (must check one):

· NO MANDATORY INDIVIDUAL ARBITRATION CLAUSES AND CLASS OR COLLECTIVE ACTION WAIVERS FOR EMPLOYEES. Bidder does NOT require its employees, as a condition of employment, to sign or agree to mandatory individual arbitration clauses or class or collective action waivers.

OR

· MANDATORY INDIVIDUAL ARBITRATION CLAUSES AND CLASS OR COLLECTIVE ACTION WAIVERS FOR EMPLOYEES. Bidder requires its employees, as a condition of employment, to sign or agree to mandatory individual arbitration clauses or class or collective action waivers.

15. TERMINATION FOR DEFAULT OR CAUSE. Bidder certifies as follows (must check one):

· NO TERMINATION FOR DEFAULT OR CAUSE. Bidder has not, within the three (3) year period preceding the date of this Competitive Solicitation, had one (1) or more federal, state, or local governmental contracts terminated for cause or default.

OR

· TERMINATION FOR DEFAULT OR CAUSE. As detailed on the attached explanation (Bidder to provide), within the three (3) year period preceding the date of this Competitive Solicitation, Bidder has had one (1) or more federal, state, or local governmental contracts terminated for cause or default.

16. TAXES. Bidder certifies as follows (must check one):

· TAXES PAID. Except as validly contested, Bidder is not delinquent and has paid or has arranged for payment of all taxes due to the State of Washington and has filed all required returns and reports as applicable.

OR

· DELINQUENT TAXES. As detailed in the attached explanation (Bidder to provide), Bidder has not paid or arranged for payment of all taxes due to the State of Washington and/or has not timely filed all required returns and reports as applicable.

17. FINANCIALLY SOLVENT. Bidder certifies as follows (must check one):

· FINANCIALLY SOLVENT. Bidder is financially stable and solvent, has adequate cash reserves to meet all financial obligations, has not commenced bankruptcy proceedings voluntarily or otherwise, and is not subject to any judgments, liens, or encumbrances of any kind affecting title to any Goods or Services that are the subject of this Competitive Solicitation.

OR

· NOT FINANCIALLY SOLVENT. As detailed on the attached explanation (Bidder to provide), Bidder is not financially stable and solvent – i.e., Bidder does not have adequate cash reserves to meet all financial obligations, has commenced bankruptcy proceedings voluntarily or otherwise, or is subject to a judgment, lien, or encumbrance that affects title to the Goods or Services that are the subject of this Competitive Solicitation.

18. LAWFUL REGISTRATION. Bidder, if conducting business other than as a sole proprietorship certifies as follows (must check one):

· CURRENT LAWFUL REGISTRATION. Bidder is in good standing in the State of Washington and the jurisdiction where Bidder is organized, including having timely filed all required annual reports.

OR

· DELINQUENT REGISTRATION. As detailed on the attached explanation (Bidder to provide), Bidder currently is not in good standing in the State of Washington and/or the jurisdiction where Bidder is organized.

NOTE: This certification applies only to bidders that are organized as separate legal entities (e.g., a corporation, partnership, limited liability company). If the bidder is a sole proprietor, this certification should not be answered.

19. REGISTRATION WITH WASHINGTON SECRETARY OF STATE. Bidder, is conducting business other than as a sole proprietorship, certifies as follows (must check one):

· BIDDER IS REGISTERED WITH WASHINGTON SECRETARY OF STATE. The Bidder is registered with the Washington Secretary of State, is in good standing, and has the following Unified Business Identifier (UBI) number: ___ ___ ___.

OR

· BIDDER WILL REGISTER WITH WASHINGTON SECRETARY OF STATE. Bidder is not registered with the Washington Secretary of State but, if designated as the Apparent Successful Bidder, Bidder will register with the Washington Secretary of State and obtain a UBI number within twenty-four (24) hours of such designation or notification by DOH or be deemed a nonresponsive bid.

OR

· BIDDER IS NOT REGISTERED WITH WASHINGTON SECRETARY OF STATE. Bidder is not registered with the Washington Secretary of State and Bidder declines to register with the Washington Secretary of State. Note: DOH requires all awarded bidders (including Washington firms and out of state firms) to be registered with the Washington Secretary of State. Bidders who are not registered will not be awarded a Contract.

NOTE: This certification applies only to bidders that are organized as separate legal entities (e.g., a corporation, partnership, limited liability company). If the bidder is a sole proprietor, this certification should not be answered.

20. REGISTRATION WITH WASHINGTON STATE DEPARTMENT OF REVENUE. Bidder certifies as follows (must check one):

· BIDDER IS REGISTERED WITH WASHINGTON STATE DEPARTMENT OF REVENUE. Bidder is registered with the Washington State Department of Revenue, has a business license to do business in Washington, and has the following Unified Business Identifier (UBI) number: ___ ___ ___.

OR

· BIDDER WILL REGISTER WITH WASHINGTON STATE DEPARTMENT OF REVENUE. Bidder is not registered with the Washington State Department of Revenue but, if designated as the Apparent Successful Bidder, Bidder will register with the Washington State Department of Revenue and obtain a business license within twenty-four (24) hours of such designation or notification by DOH or be deemed a nonresponsive bid.

OR

· BIDDER IS NOT REGISTERED WITH WASHINGTON STATE DEPARTMENT OF REVENUE. Bidder is not registered with the Washington State Department of Revenue and Bidder declines to register with the Washington State Department of Revenue. Note: DOH requires all awarded bidders (including Washington firms and out of state firms) to be registered with the Washington State Department of Revenue. Bidders who are not registered will not be awarded a Contract.

21. SUBCONTRACTORS. Bidder certifies as follows (must check one):

· NO SUBCONTRACTORS. If awarded a Contract, Bidder will not utilize subcontractors to provide the goods and/or services subject to this Competitive Solicitation.

OR

· SUBCONTRACTORS. As detailed in the attached explanation ( Attachment A Bidder Profile), if awarded a Contract, Bidder will utilize subcontractors to provide the goods and/or services subject to this Competitive Solicitation. In such an event, Bidder certifies that, as to DOH, Bidder shall retain responsibility for its subcontractors, including, without limitation, liability for any subcontractor’s acts or omissions. Note: Bidder must provide the precise legal name (including state of organization), business address, and federal tax identification number (TIN) for each subcontractor. Note: Do not provide any SSN.

22. WASHINGTON SMALL BUSINESS. Bidder certifies as follows (must check one):

· WASHINGTON SMALL BUSINESS. A bidder is a Washington Small Business as defined in RCW 39.26.010. To qualify as a Washington Small Business, Bidder must meet three (3) requirements:

· Location. Bidder’s principal office/place of business must be located in and identified as being in the State of Washington. A principal office or principal place of business is a firm’s headquarters where business decisions are made and the location for the firm’s books and records as well as the firm’s senior management personnel.

· Size. Bidder must be owned and operated independently from all other businesses and have either: (a) fifty (50) or fewer employees; or (b) gross revenue of less than seven million dollars ($7,000,000) annually as reported on Bidder’s federal income tax return, or its return filed with the Washington State Department of Revenue over the previous three consecutive years.

· WEBS Certification. Bidder must have self-certified its Washington Small Business status in Washington’s Electronic Business Solution (WEBS).

OR

· NOT WASHINGTON SMALL BUSINESS. Bidder is not a Washington Small Business as defined in RCW 39.26.010.

23. CERTIFIED VETERAN-OWNED BUSINESS. Bidder certifies as follows (must check one):

· CERTIFIED VETERAN-OWNED BUSINESS. Bidder is a Certified Veteran-Owned Business under RCW 43.60A.190. To qualify as a Certified Veteran-Owned Business, Bidder must meet four (4) requirements:

· 51% Ownership. Bidder must be at least fifty-one percent (51%) owned and controlled by:

(a) A veteran as defined as every person who at the time he or she seeks certification has received a discharge with an honorable characterization or received a discharge for medical reasons with an honorable record, where applicable, and who has served in at least one of the capacities listed in RCW 41.04.007;

(b) A person who is in receipt of disability compensation or pension from the department of veterans’ affairs; or

(c) An active or reserve member in any branch of the armed forces of the United States, including the national guard, coast guard, and armed forces reserves.

· Washington Incorporation/Location. The bidder must be either an entity that is incorporated in the state of Washington as a Washington domestic corporation or, if not incorporated, an entity whose principal place of business is located within the State of Washington.

· WEBS Certification. Bidder must have certified its Veteran-Owned business status in Washington’s Electronic Business Solution (WEBS).

· WDVA Certification. Bidder must have provided certification documentation to the Washington Department of Veterans’ Affairs WDVA) and be certified by WDVA and listed as such on WDVA’s website (WDVA – Veteran-Owned Businesses).

OR

· NOT A CERTIFIED VETERAN-OWNED BUSINESS. Bidder is not a Certified Veteran-Owned Business under RCW 43.60A.190.

24. WASHINGTON STATE ENTERPRISE LEADERSHIP COMPETENCIES – DIVERSITY, EQUITY, & INCLUSION. Bidder certifies as follows (must check one):

· UNDERSTANDS & WILL FOLLOW WASHINGTON STATE ENTERPRISE LEADERSHIP COMPETENCIES. Bidder has reviewed, understands, and if awarded a Contract, will follow the Washington State Enterprise Leadership Competencies in performing such Contract and, if utilizing subcontractors, will ensure that such subcontractors also follow the Washington State Enterprise Leadership Competencies in performing such Contract.

OR

· DOES NOT FOLLOW WASHINGTON STATE ENTERPRISE LEADERSHIP COMPETENCIES. Bidder does not follow the Washington State Enterprise Leadership Competencies.

25. SOFTWARE, EQUIPMENT, PERSONNEL, & SUPPLIES. Bidder certifies as follows (must check one):

· HAS SOFTWARE, EQUIPMENT, PERSONNEL, & SUPPLIES. Bidder currently possesses all necessary software, equipment, qualified personnel, and supplies to provide the services as defined in the solicitation.

OR

· WILL OBTAIN SOFTWARE, EQUIPMENT, PERSONNEL, & SUPPLIES. Bidder does not currently possess all necessary software, equipment, qualified personnel, and supplies to provide the services as defined in the solicitation, but, if designated as the Apparent Successful Bidder, Bidder will provide evidence satisfactory to DOH that it has obtained and possess all necessary software, equipment, qualified personnel, and supplies to provide the services as defined in the solicitation, without exception of any kind, to DOH within twenty-four (24) hours of such designation or notification by DOH or be deemed a nonresponsive bid.

OR

· DOES NOT HAVE SOFTWARE, EQUIPMENT, PERSONNEL, & SUPPLIES. Bidder currently does not possess all necessary software, equipment, qualified personnel, or supplies to provide the services as defined in the solicitation.

26. REFERENCES. Bidder certifies that the references provided to DOH have worked with Bidder and that such individuals and firms have full permission, without any additional requirement or release, to provide such references and information to DOH . Bidder hereby authorizes DOH (or its agent) to contact Bidder’s references and others who may have pertinent information regarding Bidder’s prior experience and ability to fulfil the Contract, if awarded. The Bidder hereby authorizes such individuals and firms to provide such references and release to DOH information pertaining to the same.

27. STATUTORY PREFERENCE FOR PCB-FREE PRODUCTS & PRODUCTS-IN-PACKAGING. Pursuant to RCW 39.26.280, Enterprise Services is providing a bid preference in the amount of five percent (5%) to any bidder that provides products or products-in-packaging that do not contain Polychlorinated Biphenyls (PCBs). All bidders must certify whether they are seeking the Statutory Preference for PCB-Free Products & Products-In-Packaging. Bidders who seek to obtain the five percent (5%) bid preference for PCB-Free Products & Products-In-Packaging must, in regard to the products and products-in-packaging pertaining to this Competitive Solicitation, certify either (a) that all of their products & products-in packaging; or (b) specific products & products-in-packaging are PCB-free. To be deemed to be ‘PCB-free,’ the applicable products must be tested, within the previous 365 days, by an independent, third-party laboratory using Environmental Protection Agency Analytical Method 1668c, and have been found NOT to contain PCBs. Such a test for the applicable products must be attached to this certification. Bidder certifies as follows (must check one):

· NO BID PREFERENCE. The bidder is not seeking a bid preference for PCB-Free Products & Products-In-Packaging.

OR

· BID PREFERENCE FOR ALL PRODUCTS & PRODUCTS-IN-PACKAGING. Bidder is seeking a bid preference for all of Bidder’s products pertaining to the above referenced Competitive Solicitation. Bidder certifies that each and all of Bidder’s products identified in the above referenced Competitive Solicitation have been tested, within the previous 365 days, by an independent, third-party laboratory using Environmental Protection Agency Analytical Method 1668c, and have been found NOT to contain PCBs. Bidder further certifies that the attached test results are the official test results for such products.

OR

· BID PREFERENCE FOR SPECIFIC PRODUCTS & PRODUCTS-IN-PACKAGING. Bidder IS seeking a bid preference for Bidder’s following specific product(s) pertaining to the above referenced Competitive Solicitation. Bidder certifies that each of Bidder’s listed product(s) pertaining to the above referenced Competitive Solicitation have been tested, within the previous 365 days, by an independent, third-party laboratory using Environmental Protection Agency Analytical Method 1668c, and have been found NOT to contain PCBs. The Bidder further certifies that the attached test results are the official test results for such product(s).

PRODUCT: __________________________________________________

PRODUCT: __________________________________________________

PRODUCT: __________________________________________________

*ADD ATTACHMENT IF NECESSARY

Bidder further certifies that it shall provide immediate written notice to DOH if, at any time prior to a contract award, Bidder learns that any of its certifications set forth herein were erroneous when submitted or has become erroneous by reason of changed circumstances.

I hereby certify, under penalty of perjury under the laws of the State of Washington, that the certifications herein are true and correct and that I am duly authorized to make these certifications on behalf of the Bidder listed herein.

If Bidder is a sole proprietor, print the full legal name of the individual who is the Bidder submitting the Bid

Title:

Title of person signing certificate Date:

Print Name of person making certifications for Bidder Place:

Print city and state where signed

*Attachment C Bidder’s Certification form must be completed, signed and returned in its entirety to the Solicitation Coordinator at: Bids@doh.wa.gov

ATTACHMENT C – BIDDER’S CERTIFICATIONS

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