bidcover~16.docx

BID COVER SHEET ITB #S-73000-00015172

Oregon Department of Transportation

DUNS Number (if available):

|_| Corporation |_| Professional Corporation |_| Ltd. Liability Company |_| Partnership |_| Limited Partnership |_| Ltd. Liability Partnership |_| Sole Proprietorship |_| Other

As defined in ORS 279A.120(1), Bidder is a |_| "resident bidder” or |_| “nonresident bidder”.

Physical address:

Primary contact for this Bid: Email: Phone:

Person authorized to sign Contract/Price Agreement Name: Email: Phone:

Contract Administrator for the prospective Contract/Price Agreement:

Email: Phone: Mailing address: (|_|Same as above)

2. BIDDER EXPERIENCE/QUALIFICATIONS

Number of Employees: ; Annual Sales:

Number of years in business providing Goods or Services comparable to those described in the ITB:

Construction Contractors Board License Number: ; Expiration Date:

3. BUY OREGON PREFERENCE [Delete if Federally funded or if not applicable to this procurement.] As stated in Section 7.2.4 of the ITB, ODOT will apply a preference for Goods and Services fabricated or processed entirely in Oregon, in accordance with ORS 279A.128. By checking one of the boxes below, Bidder certifies that the specified Bid items qualify for the Buy Oregon Preference:

All Bid items are fabricated or processed entirely in Oregon.

Some individual Bid items are fabricated or processed entirely in Oregon. If checked, list below the Bid line-items that are fabricated or processed entirely in Oregon:

4. BIDDER CERTIFICATIONS

As the authorized representative named below, I certify on behalf of Bidder that:

1. Bidder has reviewed all Addenda to this ITB, including: Addendum # thru Addendum # .

2. If awarded an Agreement, Bidder agrees to meet the performance standards set forth in the final Agreement, and shall comply with all requirements and Specifications within the ITB (including the Sample Agreement) and all Addenda, if any.

3. If Bidder is awarded an Agreement, all pricing submitted on the Price Form will be effective for a minimum of 15 years.

4. All contents of the Bid and this Cover Sheet are truthful and accurate.

5. In accordance with ORS 279A.110(4), Bidder does not discriminate in its employment practices with regard to race, creed, age, religious affiliation, sex, disability, sexual orientation or national origin. And, pursuant to ORS 279A.110, Bidder has not and Bidder will not discriminate against a subcontractor in the awarding of a subcontract because the subcontractor is a disadvantaged business enterprise, a minority-owned business, a woman-owned business, a business that a veteran owns or an emerging small business certified under ORS 200.055.

6. Bidder has an operating policy supporting equal employment opportunity.

7. Bidder accepts all the terms and conditions contained in the ITB and the Sample Agreement (Note: Bidder must select “Yes” on Terms & Conditions tab in OregonBuys or the Bid will be rejected).

8. Neither the Bidder, a major partner (defined as a partner or shareholder owning 10% or more of Bidder’s firm) or a major subcontractor (defined as receiving 10% or more of the total Agreement amount), nor any principal officer of a Bidder, major partner, major shareholder or major subcontractor:

a) is presently debarred, suspended, proposed for debarment under ORS 279B.130, or declared ineligible for the award of contracts by any federal agency or agency of the State of Oregon;

b) has an active exclusion on the System for Award Management (SAM) which is available at https://sam.gov/; or

c) has, within the last 3-year period, been convicted of or had a civil judgment rendered against them for: i) commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, state, or local) contract or subcontract; ii) violation of federal or state antitrust statutes relating to the submission of bids or Proposals; or iii) commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, or receiving stolen property.

{A "principal officer of a Bidder, major partner, major shareholder or major subcontractor," means an officer, director, owner, or partner and any person having primary management or supervisory responsibilities within a business entity (e.g., general manager; plant manager; head of a subsidiary, division, or business segment, and similar positions)}

9. Bidder has made all required Conflict of Interest (COI) disclosures, if any, and:

(Check one of the following two certifications as applicable) |_| Bidder and (to the best of the below-named authorized representative’s information, knowledge and belief) Bidder’s Associates (as defined in the COI Guidelines) are in conformance with the COI Guidelines, have no employees that were employed by ODOT within the last two-year period, and have no COI or other disclosures required per the COI Guidelines. The response to each question on the COI Disclosure Form was “no”.

|_| Bidder and (to the best of the below-named authorized representative’s information, knowledge and belief) all Associates (as defined in the COI Guidelines) have provided on the COI Disclosure Form(s) submitted with this Proposal all disclosures required per the ODOT COI Guidelines.

(The ODOT COI Guidelines and COI Disclosure Form are available at the following link: https://www.oregon.gov/ODOT/Business/Procurement/Pages/PSK.aspx (under “Misc. Procurement Related Forms”)

10. Bidder is an independent contractor as defined in ORS 670.600 and as described in IRS Publication 1779, which is available at the following link: https://www.irs.gov/pub/irs-pdf/p1779.pdf.

11. Under penalty of perjury, the Bidder is, to the best of the below-named authorized representative’s knowledge, not in violation of any tax laws for taxes 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 local taxes administered by the Department of Revenue under ORS 305.620. [Ref ORS 305.385(6)]

12. If applicable, Bidder has, or will have prior to contract 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 contract with an anticipated contract price of $150,000 or more with a Proposer that does not certify it has such a policy and practice. See additional information and sample policy template.)

13. By entering my name and title below and checking the “APPROVED” checkbox, I certify I am an authorized representative of the Bidder, duly authorized to bind the Bidder and make all representations, attestations, and certifications contained in the Bid and to submit the Bid on behalf of Bidder.

Title Date xx/xx/xxxx

BID COVER SHEET – APPENDIX 1

REFERENCES

(Must be returned with Bid)

REFERENCES FOR COMPARABLE PROJECTS IN SIZE AND SCOPE: Bidder shall provide a list of three different firms for references that can be contacted regarding the quality of Goods and/or Services that the Bidder provided on contracts of comparable size and scope.

Name of Firm:

Reference Contact Person:

Alternate Reference Contact Person:

Project/Contract Title:

Description of Goods and/or Services delivered:

Name of Firm:

Reference Contact Person:

Alternate Reference Contact Person:

Project/Contract Title:

Description of Goods and/or Services delivered:

Name of Firm:

Reference Contact Person:

Alternate Reference Contact Person:

Project/Contract Title:

Description of Goods and/or Services delivered:

[Optional language for price agreements]

EMPLOYEE INFORMATION

Bidder shall provide, on its letterhead, the following information on each employee that Bidder intends to assign to projects under an awarded Price Agreement:

Employee name Length of employee’s employment with Bidder’s company to date Employee’s job responsibilities with Bidder’s company Employee’s experience performing work similar to the work described in this ITB (This information should include specific projects that meet the specifications identified in the ITB and any attachments thereto.)

Certifications/licenses that employee currently holds

Bid Cover Sheet (S013-G 050523R1)