Attachment B Offeror Information and Certification Sheet~3.pdf

RFP # S-44300-00010099– Internal Agency #5899) VISTA NEW MEMBER ORIENTATION LOCATION FOR MEETINGS Att B

DAS Procurement Services, Version 1.0 – February 20, 2019 Page 1 of 2

ATTACHMENT B — OFFEROR INFORMATION AND

CERTIFICATION SHEET

Legal Name of Offeror:

Address: City, State, Zip:

Contact Person: Telephone:

Email:

State of Incorporation: Entity Type:

Oregon Secretary of State Business Registry Number (required): ____________________________________

Any individual signing below hereby certifies he/she is an authorized representative of Offeror and that:

1. Offeror understands and accepts the requirements of this RFP S-44300-00010099. By submitting a Offer, Offeror agrees to be bound by the Purchase Order terms and conditions in Attachment A , as modified by Addenda, if any.

2. Offeror acknowledges receipt of any and all Addenda to this RFP.

3. If awarded a Purchase Order, Offeror agrees to comply with all provisions of the RFP and meet the performance standards set forth in the Purchase Order.

4. Offeror has no undisclosed liquidated and delinquent debt owed to the State or any department or agency of the State.

5. I have knowledge regarding Offeror’s payment of taxes and by signing below I hereby certify, to the best of my knowledge, Offeror 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.

6. Offeror does not discriminate in its employment practices with regard to race, creed, age, religious affiliation, gender, disability, sexual orientation, national origin. When awarding subcontracts, Offeror 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 service-disabled veteran owned business, or an emerging small business. If applicable, Proposer has, or will have prior to Purchase Order execution, a written policy and practice, that meets the requirements described in ORS 279A.112, of preventing sexual harassment, sexual assault and discrimination against employees who are members of a protected class. Agency may not enter into a Purchase Order with an anticipated Purchase Order price of $150,000 or more with a Proposer that does not certify it has such a policy and practice. See https://www.oregon.gov/DAS/Procurement/Pages/hb3060.aspx for additional information and sample policy template.

7. Offeror and Offeror’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.oregon.gov/DAS/Procurement/Pages/hb3060.aspx

RFP # S-44300-00010099– Internal Agency #5899) VISTA NEW MEMBER ORIENTATION LOCATION FOR MEETINGS Att B

DAS Procurement Services, Version 1.0 – February 20, 2019 Page 2 of 2 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

8. Offeror certifies to the best of its knowledge, there exists no actual or potential conflict between the business or economic interests of Offeror, 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 RFP. If any changes occur with respect to Offeror’s status regarding conflict of interest, Offeror shall promptly notify the State in writing.

9. Offeror certifies all contents of the Bid (including any other forms or documentation, if required under this RFP), and this document are truthful and accurate and have been prepared independently from all other Offerors, and without collusion, fraud, or other dishonesty.

10. Offeror understands any statement or representation made in response to this RFP, 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 Purchase Order 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.

11. Offeror acknowledges these certifications are in addition to any certifications required in the Purchase Order.

1. 2. 3.

Authorized Signature Date

4. 5. 6.

(Printed Name and Title) 7.

Email Address https://www.treasury.gov/ofac/downloads/sdnlist.pdf https://www.sam.gov/portal/SAM/%231