RFP 00002490 Attachment I Sample Equity Contractor Declaration Form.pdf

OMF, Procurement Services ICM Toolkit: Equity Contractor Declaration Form 120922

CITY OF PORTLAND

EQUITY CONTRACTOR DECLARATION FORM

Instructions: Firms and City Bureaus should review the Inclusive Contracting Policy https://www.portland.gov/council/documents/ordinance/passed/190782, as it pertains to the City’s acceptance of alternative agency certifications in addition to COBID certification toward meeting established equity in contracting goals. Contracts awarded to Equity Contractors under Portland City Codes 5.33 5.34, or 5.68 who are not COBID certified may not exceed $150,000. Firms should complete Steps 1 through 7.

Step 1: Eligibility Requirements: Firms must meet the definition of an Equity Contractor.

“Commercially Useful Function” or “CUF” means: To perform a commercially useful function, an Equity Contractor must carry out its contract responsibilities by actually performing, managing, and supervising the work involved.

“Equity Contractor” means either: 1) a Business Oregon COBID Certified business; or, 2) a minority-owned and/or woman-owned business that is not currently COBID Certified, has business certification through a City approved alternative certification agency; or, is a Self-Identified Local Minority-owned Business; or, is a Self-Identified Local Woman-owned business; and the business performs a Commercially Useful Function.

Step 2: My firm meets the definition of an Equity Contractor as defined in Step 1 and is certifying as a:

Self-Identified Local Minority-owned Businesses

Self-Identified Local Women-owned Businesses

Self-Identified Local Non-Profit

Alternative Certification: (Must complete section 2a below)

2a. Identify the agency your business currently holds alternative certification with below. Check all that apply.

Certifying Agency:

National Minority Supplier Development Council (NMSDC)

Women’s Business Enterprise National Council (WBENC)

Washington State Office of Minority and Women Business Enterprises (OMWBE)

Certification Type:

Certification Expiration Date:

Step 3: Business Information

Business Name as registered with the Oregon Secretary of State:

DBA Name as registered with the Oregon Secretary of State:

Name of Parent Company, if applicable: Number of Employees:

EXHIBIT O

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ICM Toolkit: Equity Contractor Declaration Form 120922

Business Physical Street Address City: State: Zip code:

PO Box: City: State: Zip code:

Website address: Business Phone:

Name of Business Owner(s): Email Address: Cell Phone:

Primary Business Contact: Email Address: Cell Phone:

3a. Does your business meet the City’s standard contract compliance requirements?

The following Business Registration are required for all entities seeking to obtain a City of Portland Contract:

Yes No Oregon Secretary of State https://egov.sos.state.or.us/br/pkg_web_name_srch_inq.login

Yes No City of Portland Revenue Division https://pro.portland.gov/_/

Yes No City of Portland vendor portal: BuySpeed https://procure.portlandoregon.gov/bso/

Step 4: NIGP Codes List all NIGP Codes that apply to your business. Use the “NIGP Class, Class-Item and Category List” found on BuySpeed: https://procure.portlandoregon.gov/bso/

NIGP Code

ICM Toolkit: Equity Contractor Declaration Form 120922

Step 5: Business Classifications Select ALL that apply. For example, a Veteran-Owned Small Business should select VOSB and VBE. Only choose those business classifications that are relevant to the NIGP codes listed above.

Minority Business Enterprise (MBE)

Women Business Enterprise (WBE)

Veteran Business Enterprise (VBE)

Disadvantaged Business Enterprise (DBE)

Emerging Small Business (ESB)

Service Disabled Veteran Business Enterprise (SDVBE)

LGBT Business Enterprise (LGBTBE)

Section 3

Disabled-Owned Business Enterprise (DOBE)

Small Disadvantaged Business (SDB)

Women-Owned Small Business (WOSB)

Economically Disadvantaged Women Owned Small Business (ED-WOSB)

Veteran-Owned Small Business (VOSB)

Service-Disabled Veteran-Owned Small Business (SD-VOSB) SBA 8(a) Certified Business

DOT Certified Disadvantaged Business Enterprise (DBE)

SBA Certified HUBZone Small Business (does NOT apply for state (HUBZones) Alaskan Native Corporation (ANC)

Step 6: Please tell us how your business registers for certification.

6a. Owner Gender Gender of the owner/controller with 51% or more ownership. Indicate below the gender of the business owner/controller:

6b. Owner Ethnicity Ethnicity of the owner/controller with 51% or more ownership. Indicate below the Ethnicity of the business owner/controller:

Step 7: Business Owner Declaration

I declare, under penalty of perjury, that the foregoing statements and information provided in all sections of this application are correct and true as of the date of this application; and will be relied on by THE CITY OF PORTLAND, OREGON in awarding the Contract(s) for which this application is submitted. My firm understands that any misstatement in this application is and shall be treated as fraudulent concealment from THE CITY OF PORTLAND, OREGON of the true facts relating to the submission of bids for this Contract. I further certify that any additional information that is requested by the City of Portland and that I provide in response in order for the City to process this application will be true and correct.

Business Owner Signature:

Title:

Printed Name:

ICM Toolkit: Equity Contractor Declaration Form 120922

*****NOTICE*****

The City of Portland Auditor’s Office maintains a Fraud Hotline where anyone can make an anonymous request for investigation if they suspect fraud, waste, and abuse of City resources.

• https://www.portland.gov/audit-services/fraud-hotline

ORS 200.065, PCC 5.33.540, and PCC 5.34.535 prohibit fraudulent conduct with penalties and other sanctions including financial penalties and a three-year probation of participating in public contracts.

• https://www.oregonlegislature.gov/bills_laws/ors/ors200.html

• https://www.portland.gov/code/5/33/540

• https://www.portland.gov/code/5/34/535