Attachment 3 PTE COBID Participation Disclosure Form.pdf
PDF 140 KB Posted
- Attached to
- Employee Benefit Plan Consulting Services
- Solicitation number
- 00002426
- Issued by
- Oregon
About this file
This is a Professional Technical & Expert (PTE) Services Participation Disclosure Form issued by the City of Portland for use in response to a Request for Proposal (RFP) for Employee Benefit Plan Consulting Services in Oregon. The form is a mandatory submission requirement for all proposers and must be completed and submitted with proposals; failure to submit the form may result in the proposal being rejected as non-responsive. Proposers are required to disclose comprehensive information about all contract participants, including the proposer and all subconsultants, with specific details about scope of work percentages and subcontracting arrangements.
The form requires proposers to provide contact information and Employer Identification Numbers (EINs) for all participating firms, verify current State of Oregon Disadvantaged, Minority, Women, and Emerging Small Business (D/M/W/ESB) certification status, identify the percentage of proposed scope and work categories to be performed by the proposer and each subconsultant, and disclose the percentage of total contract amount allocated to Oregon certified D/M/W/ESB subconsultants. All fields must be completed with specific information; the use of "TBD," "N/A," or similar placeholders is not acceptable. If no subconsultants will be used, the proposer must still complete the form with its own information and indicate "NONE" in the subconsultant section. Social Security Numbers are prohibited from the form, and certification status can be verified through the State of Oregon Office of Disadvantaged, Minority, Women, and Emerging Small Business database.
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Text version
CITY OF PORTLAND
PROFESSIONAL TECHNICAL & EXPERT (PTE) SERVICES
PARTICIPATION DISCLOSURE FORM 1
CITY PTE DISCLOSURE REQUIREMENTS
The City’s disclosure program was adopted to document the utilization of State of Oregon certified Disadvantaged, Minority, Women and Emerging Small Businesses (D/M/W/ESBs) on City projects.
This Request for Proposal (RFP) requires submission by the Proposer of the PTE Participation Disclosure Form 1. The Proposer must disclose the following information:
1) Contact information and Employer Identification Number (EIN or FED ID#) for all contract participants
2) State of Oregon D/M/W/ESB designation
(Verify current certification status with the Office of Disadvantaged, Minority, Women, and Emerging Small Business.
3) The percentage of proposed scope or category of work that the Proposer will be performing.
4) The percentage of proposed scope or category of work that any subconsultants will be performing
5) Percentage of total contract amount allocated to Oregon certified D/M/W/ESB subconsultants.
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 subconsultants, the Proposer is still required to enter its own information in the appropriate section and to indicate “NONE” in the subconsultant section of the accompanying form and submit the form with its proposal.
FAILURE TO SUBMIT THE PTE PARTICIPATION DISCLOSURE FORM 1 WITH THE PROPOSAL MAY RESULT IN THE
PROPOSAL BEING FOUND NON-RESPONSIVE AND REJECTED FROM CONSIDERATION.
CITY OF PORTLAND
PTE PARTICIPATION DISCLOSURE FORM 1
This Request for Proposals (RFP) requires the Proposer to submit this PTE Participation Disclosure Form 1. Failure to submit this form with the proposal may result in the proposal being found non-responsive and rejected. Proposers must disclose the following information:
Please print all information clearly.
Project Name: _____________________________________________________ RFP Number: ______________
Proposer Name: ________________________________________________ Proposer’s EIN #: ______________ Contact Name: ______________________________ Phone: ____________ Email: _______________________
Proposer’s Total Percentage: _______%
Combined percentage of total price agreement amount allocated to State of Oregon certified D/M/W/ESB subcontracts (Subconsultants only): %
SUBCONSULTANT INFORMATION (please print)1 D/M/W/ESB Cert.2
Subconsultant Scope/Type of
Work
Subcontract
Firm Legal Name:
Email:
Phone #:
EIN #4:
Firm Legal Name:
Email:
EIN #:
NOTE:
1. If the Proposer will not be using any Subconsultants, the Proposer is required to indicate “NONE” in the
Subconsultant Information section of this form and submit this form with their proposal.
2. The Proposer and ALL Subconsultants must be listed on this form. Leave D/M/W/ESB column blank if firm is not currently certified through the State of Oregon Office of Disadvantaged, Minority, Women, and Emerging Small Business:
https://oregon4biz.diversitysoftware.com/FrontEnd/VendorSearchPublic.asp.
3. Using ‘TBD’, ‘N/A’, or similar acronyms is not acceptable.
4. Do not enter Social Security Numbers (SSN) on this form.
https://oregon4biz.diversitysoftware.com/FrontEnd/VendorSearchPublic.asp
SUBCONSULTANT INFORMATION (please print) D/M/W/ESB Cert.
Subconsultant Scope/Type of
Work
Subcontract
Firm Legal Name:
Email:
| 1) Contact information and Employer Identification Number (EIN or FED ID#) for all contract participants |
| 2) State of Oregon D/M/W/ESB designation |
| (Verify current certification status with the Office of Disadvantaged, Minority, Women, and Emerging Small Business. |
| 3) The percentage of proposed scope or category of work that the Proposer will be performing. |
| 4) The percentage of proposed scope or category of work that any subconsultants will be performing |
| 5) Percentage of total contract amount allocated to Oregon certified D/M/W/ESB subconsultants. |
| 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 subconsultants, the Proposer is still required to enter its own information in the appropriate section and to indicate “NONE” in the subconsultant section of the accompanying form and submit the form with its prop... |
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