EXHIBIT B - Bidder Profile Form.docx

EXHIBIT B

BIDDER PROFILE FORM

Provide the requested Bidder information in each Section below. Where indicated, Bidders must also provide answers for Subcontractors that Bidders anticipate using for the work.

1. General Information A. Name, address, principal place of business, telephone number, fax number and email address of Bidder’s legal entity with which DOC may enter into a contract.

Bidder response:

B. Name, address, principal place of business, telephone number, fax number and email address of any Subcontractors.

Bidder response:

C. Name, telephone number, and email address of each principal officer (President, Vice President, Treasurer, Chairperson of the Board of Directors, etc.) of the Bidder.

Bidder response:

D. Identify Bidder’s sole contact person for this Bid who will have the authority to represent the Bidder. Include the name, title, address, telephone and fax numbers and email address.

If the need arises for the Washington State Department of Corrections (DOC) to clarify any portion of the Bidder’s Bid, the RFP Coordinator will attempt to contact this person. DOC expects that this Bidder contact will be timely in responding and will be reasonable in all related communication with DOC.

Bidder response:

E. Legal status of the Bidder (sole proprietorship, partnership, corporation, etc.), the year the entity was organized to do business as the entity now substantially exists, and the year the entity was registered or qualified to do business in Washington State.

Bidder response:

F. Bidder’s Federal Employer Tax Identification number and the Washington Uniform Business Identification (UBI) number issued by the state of Washington Department of Revenue. If the Bidder does not have a UBI number, the Bidder must state that it will obtain one by becoming licensed in Washington within thirty (30) calendar days of being selected as the apparent successful Bidder.

Bidder response:

G. Has the Bidder, Subcontractors, Third Party Providers, or any of their principle owners or partners been debarred or prohibited from submitting a Bid, having a Bid considered or entering into a public contract by any public entity or governmental agency within the last five (5) years?

Bidder response:

Bidder response for Subcontractor(s):

H. Include a description of the Bidder and any Subcontractor’s core business, services offered, types of customers, number of employees, and size of operations.

Bidder response:

Bidder response for Subcontractor(s):

I. Identify if Bidder or any Subcontractors meet the definitions, desirable criteria and/or certifications listed in Section 3.3 of the RFP, Small Business and Veteran-Owned Business Participation. If not applicable, so indicate.

2. Current or Former State Employee(s) A. Identify any current or former employee of the state of Washington on the Bidder’s and any Subcontractor’s governing board as of the date of the Bid. Include their position and responsibilities within the Bidder’s organization. If not applicable, so indicate.

If, following a review of this information, it is determined by DOC that a conflict of interest exists, the Bidder may be disqualified from further consideration for the award of a contract.

B. If the Bidder’s staff or Subcontractor’s staff was an employee of the state of Washington at any time during the past 24 months, or is currently an employee of the state of Washington, identify the individual by name, the agency previously or currently employed by, job title or position held and separation date. If not applicable, so indicate.

Bidder response for Subcontractor(s):

Bidder response:

3. Threatened Defaults, Terminations and Litigations A. "If the Bidder or Subcontractor has had a customer contract terminated for default, threatened to be terminated for default or has received a written notice of default in the last five years, describe such incident. For publicly-held companies, do not refer DOC to Bidder's financial statements or state that there is no material litigation; rather, any customer contract arrangements that fall within the foregoing description must be disclosed.

Submit full details of the terms of the incident including the customer and/or other adverse party name, address, and telephone number. Present the Bidder’s position on the matter. DOC reserves the right to contact the customer or other adverse party and their representatives for further investigation of the incident. DOC will evaluate the facts and may, at its sole discretion, reject the Bid on the grounds of the past experience.

If no such termination, threatened termination or written notice of default has been experienced by the Bidder, Subcontractors, or Third Party Providers in the past five years, so indicate.

4. RFP and Bid Statements A. State that the Bidder acknowledges and agrees to all of the rights of DOC expressed in this RFP.

Bidder response:

B. State specifically whether or not the Bid contains any proprietary information and identify (by document name, page number and location on page) where the proprietary information is in Bidder’s response. Stating or marking the entire Bid or entire Sections as proprietary will not be honored. DOC will reject Bids where pricing is marked as proprietary.

Bidder response:

C. State any additional representations, promises, warranties, and/or other information as the Bidder deems appropriate and wishes to convey to DOC.

Bidder response:

5. Procurement or Financial-Related Convictions A. Indicate whether the Bidder or Subcontractor, or any of the Bidder or subcontractor principle owners, officers or partners are currently under investigation for or have been convicted within the last ten (10) years of any of the following :

(a) Conviction for commission of a criminal offense as an incident to obtaining or attempting to obtain a public or private contract or subcontract, or in the performance of such contract or subcontract.

(b) Conviction or a final determination in a civil action under state or federal statutes of fraud, embezzlement, theft, forgery, bribery, falsification or destruction of records, receiving stolen property, violation of the federal false claims act, 31 U.S.C. Sec. 3729 et seq., or the state Medicaid fraud false claims act, chapter 74.66 RCW, or any other offense indicating a lack of business integrity or business honesty.

(c) Conviction under state or federal antitrust statutes arising out of the submission of Bids or Bids.

Submit full details of the terms of the incident including the customer and/or other adverse party name, address, and telephone number. Present the Bidder’s position on the matter. DOC reserves the right to contact the customer or other adverse party and their representatives for further investigation of the incident. DOC will evaluate the facts and may, at its sole discretion, reject the Bid on the grounds of the past conviction.

If no such criminal conviction has been experienced by the Bidder or Subcontractor(s) in the past ten (10) years, so indicate.

Bidder response:

Bidder response for Subcontractor(s):