Attachment A Proposer Information and Certification Sheet~1.docx

RFP OMD-XXXX-20 – Branding and Graphics for “Be 2 Weeks Ready”

ATTACHMENT A

Proposer INFORMATION AND CERTIFICATION SHEET

Legal Name of Proposer: ___________________________________________ Address: ______________________________________________________ City, State, Zip: _____________________________ State of Incorporation: ____________________________________________ Entity Type: ________________________________________ Contact Name: _________________________________ Telephone: _____________________ Email: ____________________ Oregon Business Registry Number: __________________________________ FEIN:

I. BASE PROPOSAL: To include all work described in the RFP, SOW, Plans, Specifications and any issued Addenda.

BASE PROPOSAL LUMP SUM: $_______________________________

II. Any individual signing below hereby certifies they are an authorized representative of Proposer and that:

Proposer understands and accepts the requirements of this RFP. By submitting a Proposal, Proposer agrees to be bound by the Terms and Conditions in Attachment C (the Sample Purchase Order) and as modified by any Addenda.

Proposer acknowledges receipt of any and all Addenda to this RFP.

Proposal is a Firm Offer for 90 days following the Closing.

If issued a Purchase Order, Proposer agrees to provide the services that meet the performance standards set forth in the SOW.

I have knowledge regarding Proposer’s payment of taxes and by signing below I hereby certify that, to the best of my knowledge, Proposer is not in violation of any tax laws of the state or a political subdivision of the state, including, without limitation, ORS 305.620 and ORS chapters 316, 317 and 318.

Proposer does not discriminate in its employment practices with regard to race, creed, age, religious affiliation, gender, disability, sexual orientation, national origin. When awarding subcontracts, Proposer does not discriminate against any business certified under ORS 200.055 as a disadvantaged business enterprise, a minority-owned business, a woman-owned business, a business that a service-disabled veteran owns or an emerging small business.

Proposer and Proposer’s employees, agents, and subcontractors are not included on:

a. the “Specially Designated Nationals and Blocked Persons” list maintained by the Office of Foreign Assets Control of the United States Department of the Treasury found at: https://www.treasury.gov/ofac/downloads/sdnlist.pdf., or

b. the government wide exclusions lists in the System for Award Management found at: https://www.sam.gov/portal/SAM/#1 Proposer certifies that, to the best of its knowledge, there exists no actual or potential conflict between the business or economic interests of Proposer, its employees, or its agents, on the one hand, and the business or economic interests of the State, on the other hand, arising out of, or relating in any way to, the subject matter of the RFQ. If any changes occur with respect to Proposer’s status regarding conflict of interest, Proposer shall promptly notify the State in writing.

Proposer certifies that all contents of the Proposal (including any other forms or documentation, if required under this RFP) and this Proposer Information and Certification Sheet, are truthful and accurate and have been prepared independently from all other Proposer, and without collusion, fraud, or other dishonesty.

Proposer understands that any statement or representation it makes, in response to this RFQ, if determined to be false or fraudulent, a misrepresentation, or inaccurate because of the omission of material information could result in a "claim" {as defined by the Oregon False Claims Act, ORS 180.750(1)}, made under contract being a "false claim" {ORS 180.750(2)} 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.

Proposer acknowledges these certifications are in addition to any certifications required in the resulting Contract for Services and PWS at the time of Contract for Services execution.

(Print Name and Title)