ATTACHMENT 4 - Contractual Acceptance Form 13424~1.pdf

ITB S-47100-00013424 – ALBANY HVAC

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ATTACHMENT 4 - CONTRACTUAL ACCEPTANCE FORM

BIDDER SHALL PROVIDE ALL APPLICABLE INFORMATION REQUESTED BELOW.

THIS ATTACHMENT MUST BE COMPLETED AND RETURNED WITH BID.

BIDDER’S LEGAL NAME: (TAX FILING) _____________________________________________

PRIMARY CONTACT PERSON: _________________________TITLE: ______________________

BIDDER’S MAILING ADDRESS: ____________________________________________________

TELEPHONE: ___________________E-MAIL ADDRESS: ________________________________

BIDDER’S BUSINESS DESIGNATION: (CHECK ONE)

Partnership Limited Partnership Limited Liability Partnership Corporation Professional Corporation Limited Liability Company Sole Proprietorship Other: _____________________________

BIDDER’S FEDERAL TAX ID NUMBER: (NOT SOCIAL SECURITY NUMBER) -

Tax information is requested pursuant to ORS 305.385 and will be used for the administration of state, federal and local tax laws. OED may report the information provided to the Internal Revenue Service (IRS) under the name and taxpayer identification number provided.

BIDDER’S OREGON BUSINESS REGISTRATION NUMBER:

(OREGON SECRETARY OF STATE, CORPORATIONS DIVISION)

Go to http://www.filinginoregon.com/ for information on how to register to do business in Oregon.

BIDDER IS A RESIDENT BIDDER: YES NO

ORS 279A.120(1)(b): “Resident bidder” means a Bidder that has paid unemployment taxes or income taxes in Oregon during the 12 calendar months immediately preceding submission of the bid, has a business address in Oregon and has stated in the bid whether the Bidder is a “Resident bidder” under this paragraph.

BIDDER IS AN OREGON CERTIFIED FIRM: (CHECK ALL THAT APPLY)

Minority Business Enterprise (MBE) Emerging Small Business (ESB) Women Business Enterprise (WBE) Disadvantaged Business Enterprise (DBE)

Go to http://www.oregon4biz.com/How-We-Can-Help/OMWESB/ for information on the OMWESB certification program.

BIDDER’S AUTHORIZED REPRESENTATIVE CONTACT INFORMATION:

AUTHORIZED REPRESENTATIVE NAME TITLE

PHONE EMAIL

ITB S-47100-00013424 – ALBANY HVAC

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By signing this page and submitting a bid, the authorized representative certifies that the following statements are true:

He/she is authorized to act on behalf of Bidder.

The supplied Bidder data is true and accurate.

No attempt has been made or will be made by the Bidder to induce any other person or organization to submit or not submit a bid.

Bidder does not discriminate in its employment practices with regard to race, creed, age, religious affiliation, sex, disability, sexual orientation or national origin, nor has Bidder or will Bidder discriminate against a subcontractor in the awarding of a subcontract because the subcontractor is a minority, women or emerging small business enterprise certified under ORS 200.055.

Information and costs included in this bid shall remain valid for 30 days after the bid closing date and time or until a contract is approved, whichever comes first.

The statements contained in this bid are true and complete to the best of the Bidder’s knowledge and Bidder accepts as a condition of the contract, the obligation to comply with the applicable state and federal requirements, policies, standards, and regulations. The undersigned recognizes that this is a public document and open to public inspection.

The Bidder, by submitting a bid in response to this Invitation to Bid, certifies that it understands that any statement or representation contained in or attached to, its bid, and any statement, representation, or application the Bidder may submit under any contract OED may award under this Invitation to Bid, that constitutes a “claim” (as defined by the Oregon False Claims Act, ORS 180.750(1)), is subject to the Oregon False Claims Act, ORS 180.750 to 180.785, and to any liabilities or penalties associated with the making of a false claim under that Act.

The Bidder acknowledges receipt of all addenda issued under this Invitation to Bid.

To the best of Bidder’s knowledge, Bidder is not in violation of any Oregon tax laws.

For the purposes of this certification, “Oregon Tax Laws” means a state tax imposed by ORS

320.005 to 320.150 and 403.200 to 403.250 and ORS chapters 118, 314, 316, 317, 318, 321 and 323 and the elderly rental assistance program under ORS 310.630 to 310.706 and local taxes administered by the Department of Revenue under ORS 305.620. Bidder has completely read and understands the provisions of this Invitation to Bid, including any addenda issued.

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

Bidder accepts and agrees to be bound by all the terms and conditions of the contract awarded.

Pursuant to ORS 279B.055(2)(c), the Bidder, if awarded a contract, agrees to meet the highest standards prevalent in the industry or business most closely involved in providing the appropriate goods or services as stated in the scope of work.

SIGNATURE OF BIDDER’S AUTHORIZED REPRESENTATIVE DATE