ATTACHMENT 1 Bidders Authorized Representative Form.pdf

S-62900-00014481

ATTACHMENT 1

SIGNATURE OF BIDDER’S AUTHORIZED REPRESENTATIVE FORM

THIS FORM MUST BE COMPLETED AND RETURNED WITH BID

**This form shall be signed in ink by an authorized representative of Bidder. Any alterations or erasures shall be initialed in ink by the undersigned authorized representative.**

CONTRACTOR DATA:

Bidder shall provide the information requested below, as applicable, including Bidder’s federal tax ID number. Tax information is requested pursuant to ORS 305.385 and will be used for the administration of state, federal and local tax laws. ODF may report the information provided to the Internal Revenue Service under the name and taxpayer identification number provided.

Bidder’s Legal Name (tax filing): _______________________________________________________

Mailing Address: ___________________________________________________________________

Citizenship (if applicable): Non-resident alien [ ] Yes [ ] No

Business Designation (check one):

[ ] Corporation [ ] Professional Corporation [ ] Partnership [ ] Limited Partnership

[ ] Limited Liability Company [ ] Limited Liability Partnership [ ] Sole Proprietorship

[ ] Other ___________________________________________

Federal Tax ID: ________________________

Bidder’s Contact Information:

Authorized Representative __________________________________________________________

Phone _____________________________ Fax _____________________________

E-mail __________________________________________________

RESIDENCY INFORMATION

In determining the lowest responsible bidder, and for the purpose of awarding a contract, Oregon law requires a public contracting agency to add a percentage increase on the bid of a nonresident bidder equal to the percent, if any, of the preference given to that bidder in the state in which the bidder resides. ORS 279A.120.

“Resident bidder” means a bidder that has paid unemployment taxes or income taxes in this state during the twelve (12) calendar months immediately preceding submission of the bid, has a business address in this state and has stated in the bid whether the bidder is a resident bidder.

ORS 279A.120(1)(b).

A “Non-resident” bidder means a bidder who is not a “resident bidder” as defined above. ORS 279A.120(1)(a).

a. Check one: Bidder is a ( ) RESIDENT bidder ( ) NON-RESIDENT bidder.

b. If resident bidder, enter your Oregon business address: (physical and mailing address)

c. If a non-resident bidder, enter state of residency:_______________________________________________

d. If a non-resident bidder, do you or your firm receive, or are you or your firm eligible for, any preference in award of contracts with your state’s government or with other governmental bodies in your state?

CHECK ONE: ( ) YES ( ) NO

If yes, state the preference percentage: _________________%

If yes, but not a percentage of bid price, describe the preference:

If yes, state the law or regulation that allows the preference described (legal citation):

The individual signing on behalf of Bidder hereby acknowledges, attests and certifies individually and on behalf of the Bidder that:

• He/she is a duly authorized representative of Bidder, has been authorized by Bidder to make all representations, attestations and certifications contained in this Bid and all addenda, if any, issued, and to execute this Bid on behalf of Bidder;

• The information supplied by Bidder in this Bid is true and accurate;

• Bidder, acting through its authorized representatives, has completely read and understands all the provisions of the Solicitation, including all attachments and addenda, if any, issued;

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

• Bidder is bound by and will comply with all the provisions, requirements, specifications, and terms and conditions contained in the Invitation to Bid and Bid, including all attachments and addenda, if any, issued;

• Bidder agrees to provide all services required to be provided under the Contract in accordance with specifications and requirements, and will comply in all respects with the terms of the resulting Contract upon award;

• Bidder has the available resources, including staffing if applicable, to provide the services in a reasonable timeframe to pursue ODF’s objectives;

• Bidder has not discriminated and will not discriminate against a subcontractor in awarding a subcontract because the subcontractor is a minority, women or emerging small business enterprise certified under ORS 200.055 or against a business enterprise that is owned or controlled by or that employs a disabled veteran, as defined in ORS 408.225; and

• Bidder has a written policy and practice that meets the requirements described in HB 3060 (2017) Oregon Laws, chapter 212, of preventing sexual harassment, sexual assault and discrimination against employees who are members of a protected class.

• To the best of his other knowledge, Bidder is not in violation of any Oregon Tax Laws. For purposes of this certification, "Oregon Tax Laws" are those tax laws listed in ORS 305.380(4), namely ORS Chapters 118, 314, 316, 317, 318, 320, 321 and 323 and Sections 10 to 20, Chapter 533, Oregon Laws 1981, as amended by Chapter 16, Oregon Laws 1982 (first special session); the elderly rental assistance program under ORS 310.630 to 310.706; and any local tax laws administered by the Oregon Department of Revenue under ORS 305.620.

Signature of Bidder’s Authorized Representative Date