ATTACHMENT C - ENERGY SERVICE COMPANY INFORMATION AND CERTIFICATION SHEET 26-189 ESCO EPID RFQ Final.docx

ATTACHMENT C - AGENCY RFQ NUMBER 26-189 ESCO EPID; OREGONBUYS SOLICITATION NUMBER S-33000-00018034

ATTACHMENT C — Energy Service Company INFORMATION AND CERTIFICATION SHEET Energy Service Company Name:

Address:

City, State, Zip:

State of Incorporation:

Entity Type:

Contact Name:

Telephone:

Email:

Oregon Business Registry Number (if required):

Any individual signing below hereby certifies they are an authorized representative of Energy Service Company and that:

Energy Service Company understands and accepts the requirements of this RFQ. By submitting a SOQ, Energy Service Company agrees to be bound by the Agreement terms and conditions in RFQ Attachment A and as modified by any Addenda, except for those terms and conditions that Agency has reserved for negotiation, as identified in the RFQ.

Energy Service Company acknowledges receipt of any and all Addenda to this RFQ.

SOQ is a Firm Offer for 180 days following the SOQ Opening Date.

If awarded an Agreement, Energy Service Company agrees to perform the scope of work and meet the performance standards set forth in the final negotiated scope of services of the Agreement.

I have knowledge regarding Energy Service Company’s payment of taxes and by signing below I hereby certify that, to the best of my knowledge, Energy Service Company 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.

Energy Service Company does not discriminate in its employment practices with regard to race, creed, age, religious affiliation, gender, disability, sexual orientation, national origin. When awarding subcontracts, Energy Service Company 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. If applicable, Energy Service Company has, or will have, prior to Agreement execution, a written policy and practice, that meets the requirements described in ORS 279A.112 (formerly HB 3060), of preventing sexual harassment, sexual assault and discrimination against employees who are members of a protected class. Agency may not enter into an Agreement with an anticipated Agreement price of $150,000 or more with an Energy Service Company 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.

Energy Service Company complies with ORS 652.220 and does not unlawfully discriminate against any of Energy Service Company’s employees in the payment of wages or other compensation for work of comparable character on the basis of an employee’s membership in a protected class. “Protected class” means a group of persons distinguished by race, color, religion, sex, sexual orientation, national origin, marital status, veteran status, disability or age.

Energy Service Company’s continuing compliance constitutes a material element of this Agreement and a failure to comply constitutes a breach that entitles Agency to terminate this Agreement for cause.

Energy Service Company may not prohibit any of Energy Service Company’s employees from discussing the employee’s rate of wage, salary, benefits, or other compensation with another employee or another person. Energy Service Company may not retaliate against an employee who discusses the employee’s rate of wage, salary, benefits, or other compensation with another employee or another person.

Energy Service Company is not engaged in the provision of broadband Internet access service, or if at any time Energy Service Company is engaged in or may engage in the provision of broadband Internet access service Energy Service Company is in compliance with Oregon Laws 2018, Chapter 88 (HB 4155) and applicable Public Utility Commission rules, and will remain in compliance throughout the term of the Agreement.

Energy Service Company and Energy Service Company’s employees, agents, and subcontractors are not included on:

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 the government wide exclusions lists in the System for Award Management found at: https://www.sam.gov/portal/ Energy Service Company certifies that, to the best of its knowledge, there exists no actual or potential conflict between the business or economic interests of Energy Service Company, 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 Energy Service Company’s status regarding conflict of interest, Energy Service Company shall promptly notify the State in writing.

Energy Service Company certifies that all contents of the SOQ (including any other forms or documentation, if required under this RFQ) and this Energy Service Company Certification Sheet are truthful and accurate and have been prepared independently from all other Energy Service Companies, and without collusion, fraud, or other dishonesty.

Energy Service Company 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 Agreement 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.

Energy Service Company acknowledges these certifications are in addition to any certifications required in Attachment A, Sample Agreement, Exhibit B, Scope of Services for Maintaining Prequalification, at the time of Agreement execution.

Authorized Signature

Date

(Printed Name and Title)

AGENCY RFQ NUMBER 26-189 ESCO EPID; OREGONBUYS SOLICITATION NUMBER S-33000-00018034 Page 1 of 3