Attachment 3 PTE COBID Participation Disclosure Form~3.pdf

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: