ITB_12203_Attachment_B_Bidder_Information_and_Certification_Form.pdf

ITB No. S-10700-00012203 – Supply of Bulk Propane Fuel, Tanks, Related Goods and Services

DAS Procurement Services, Version 4.0 – December 21, 2018 Page 1 of 2

ATTACHMENT B

Bidder Information and Certification Form

Legal Name of Bidder:

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 Bidder and that:

1. Bidder understands and accepts the requirements of this ITB. By submitting a bid, Bidder agrees to be bound by the Price Agreement terms and conditions in Attachment A and as modified by any Addenda, except for those terms and conditions Agency has reserved for negotiation, as identified in the ITB or future Price Agreement.

2. Bidder acknowledges receipt of all Addenda to this ITB.

3. Bid is a Firm Offer for 180 days following the Closing.

4. If awarded a Price Agreement, Bidder agrees to perform and meet the performance standards set forth in the Price Agreement.

5. I have knowledge regarding Bidder’s payment of taxes and by signing below I hereby certify that, to the best of my knowledge, Bidder 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. Bidder does not discriminate in its employment practices regarding race, creed, age, religious affiliation, gender, disability, sexual orientation, national origin. When awarding subcontracts, Bidder 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, Bidder has, or will have prior to contract execution, a written policy and practice, meeting 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 a contract with an anticipated contract price of $150,000 or more with a Bidder 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. Bidder complies with ORS 652.220 and does not unlawfully discriminate against any of Bidder’s employees in the payment of wages or other compensation for work of comparable character based on 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.

https://www.oregon.gov/DAS/Procurement/Pages/hb3060.aspx

ITB No. S-10700-00012203 – Supply of Bulk Propane Fuel, Tanks, Related Goods and Services

DAS Procurement Services, Version 4.0 – December 21, 2018 Page 2 of 2

Bidder’s continuing compliance, if awarded a Price Agreement, constitutes a material element of the Price Agreement and a failure to comply constitutes a breach entitling Agency to terminate the Price Agreement for cause.

Bidder, if awarded a Price Agreement, may not prohibit any of its employees from discussing the employee’s rate of wage, salary, benefits, or other compensation with another employee or another person and 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.

8. Bidder is not engaged in the provision of broadband Internet access service, or if at any time Bidder is engaged in or may engage in the provision of broadband Internet access service Bidder 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 Price Agreement.

9. Bidder and Bidder’s employees, agents, and subcontractors are not included in:

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/

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

11. Bidder certifies all contents of the Bid (including any other forms or documentation, if required under this ITB) and this Bid Information and Certification form are truthful and accurate and have been prepared independently from all other Bidders, and without collusion, fraud, or other dishonesty.

12. Bidder understands that any statement or representation it makes, in response to this ITB, 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 Price 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.

13. Bidder acknowledges these certifications are in addition to any certifications required in the Price Agreement and Statement of Work in Attachment A at the time of Price Agreement execution.

Authorized Signature Date

Printed Name https://www.treasury.gov/ofac/downloads/sdnlist.pdf https://www.sam.gov/portal/