Attachment 3 COBID Participation Disclosure Form.pdf

COBID Participation Disclosure Form 1

The City’s disclosure program is used to document the utilization of businesses certified by the State’s Certification Office for Business Inclusion and Diversity (COBID) on City projects.

This Request for Proposal (RFP) requires submission by the proposer of the City’s COBID Participation Disclosure Form 1. Proposers must disclose the following information with their proposal response:

1. Contact information and Employer Identification Number (EIN or FED ID#) for all Contract participants

2. State of Oregon COBID designation. (Verify current certification status with the Office of Minority, Women, and Emerging Small Business at http://egov.oregon.gov/DCBS/OMWESB/index.shtml)

3. The proposed scope or category of work that the proposer and any subcontractors will be performing

4. The dollar amount of the proposer’s self-performing work and of all subcontractors’ contract(s)

5. Percentage of total Contract amount allocated to Oregon certified COBID participation

Report all amounts in United States Dollars (USD). The use of ‘TBD’, ‘N/A’, or similar symbols is not acceptable. All requested information must be provided.

If the proposer will not be using any subcontractors, the proposer is still required to enter its own information in the appropriate section and to indicate “NONE” in the subcontractor section of the accompanying form and submit the form with its proposal.

FAILURE TO SUBMIT THE CITY’S COBID PARTICIPATION DISCLOSURE FORM 1 WITH THE PROPOSAL

MAY RESULT IN THE PROPOSAL BEING FOUND NON-RESPONSIVE AND REJECTED FROM

CONSIDERATION.

CITY OF PORTLAND

COBID PARTICIPATION DISCLOSURE FORM 1

This Request for Proposal requires submission by the proposer of the following information and presented on this COBID PARTICIPATION DISCLOSURE FORM 1. Proposers must disclose the following information:

Please print all information clearly.

Proposer Name: _ _________ Proposer’s Total Cost: $__________

Project Name: _____ _______________ RFP Number: ___ _____

Contact Name: ______________________Phone: ____________ Email: _______________________

Percentage of total Contract amount allocated to Oregon certified COBID participation

(Proposer & subcontractors added together)

PROPOSER INFORMATION

(Please Print)

COBID

SCOPE / TYPE

OF WORK

SELF-PERFORMING

AMOUNT

Firm Legal Name:

Email:

Phone #:

Fax#:

FED ID OR EIN # (No SS#):

SUBCONTRACTOR INFORMATION

(Please Print)

COBID SCOPE / TYPE

OF WORK

SUBCONTRACT

AMOUNT

Firm Legal Name:

Email:

Phone #:

Firm Legal Name:

Email:

Phone #:

Firm Legal Name:

Email:

Phone #:

NOTE:

The proposer and all subcontractors must be listed on this form. Leave COBID column blank if firm is not confirmed as currently certified through the State of Oregon Certification Office for Business Inclusion and Diversity:

http://www.oregon4biz.com/How-We-Can-Help/COBID/

If the proposer will not be using any subcontractors, please indicate “NONE” in the Subcontractor Information section of this form.

Do not enter Social Security numbers on this form.

http://www.oregon4biz.com/How-We-Can-Help/COBID/

COBID Participation Disclosure Form 1