ITB Att C Bidder Information and Certification Sheet Final.docx

ITB S-44300-00010188 – Installation, Lease, Service, Repair, Monitor, Maintain, Calibrate and Removal Of Ignition Interlock Devices Att CDRAFT

ATTACHMENT C — BIDDER INFORMATION and CERTIFICATION SHEET

Bidder Name (printed):

Address:

City, State, Zip:

Bid Clarification Contact Person:

Telephone:

Email:

State of Incorporation:

Entity Type:

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

Any individual signing below hereby certifies he/she is 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 Contract terms and conditions in Attachment A , as modified by Addenda, if any.

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

3. If awarded a Contract, Bidder agrees to comply with all provisions of the ITB and meet the performance standards set forth in the Contract.

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

5. I have knowledge regarding Bidder’s payment of taxes and by signing below I hereby certify, 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 with regard to 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 service-disabled veteran owned business, or an emerging small business. If applicable, Proposer 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 https://www.oregon.gov/DAS/Procurement/Pages/hb3060.aspx for additional information and sample policy template.

7. Bidder and Bidder’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.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. 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.

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

10. Bidder understands any statement or representation made 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 Contract 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. Bidder acknowledges these certifications are in addition to any certifications required in the Contract at the time of execution.

Authorized Signature

Date

(Printed Name and Title)

Email Address

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