RFQ_ATTACHMENT_B_PROPOSER_INFORMATION_REVISED~1.docx

S-15000-00001403– Return-to-Operation (RTO) Service for IBML Devices

ATTACHMENT B — PROPOSER INFORMATION AND CERTIFICATION SHEET

Legal Name of Proposer: ___________________________________________ Address: ______________________________________________________________ City, State, Zip: ____________________________________________ State of Incorporation: ____________________________________________ Entity Type: ________________________________________________ Contact Name:__________________________________________ Telephone: _________________________ Email: ____________________________ Oregon Business Registry Number (if required):__________________________________ Federal Taxpayer ID #:_________________________________________________________________ Number of Full-Time Employees:____________________________________________________ Any individual signing below hereby certifies they are an authorized representative of Proposer and that:

Proposer understands and accepts the requirements of this RFQ.

Proposer acknowledges receipt of any and all Addenda to this RFQ.

Proposal is a Firm Offer for 180 days following the Closing.

If awarded a Contract, Proposer agrees to provide the required Services and meet the performance standards set forth in the final Contract.

I have knowledge regarding Proposer’s payment of taxes and by signing below I hereby certify that, to the best of my knowledge, Proposer 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.

Proposer does not discriminate in its employment practices with regard to race, creed, age, religious affiliation, gender, disability, sexual orientation, and national origin. Furthermore, that in accordance with House Bill 3060 (2017 Oregon Laws, chapter 212), Proposer has in place, or will have by the time of Contract execution, a policy and practice of preventing sexual harassment, sexual assault, and discrimination against employees who are members of a protected class; and that Proposer will maintain such policy and practice in force during the term of the Contract. When awarding subcontracts, Proposer 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.

Proposer and Proposer’s employees, agents, and subcontractors are not included on:

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 the government wide exclusions lists in the System for Award Management found at: https://www.sam.gov/portal/SAM/#1 Proposer certifies that, to the best of its knowledge, there exists no actual or potential conflict between the business or economic interests of Proposer, 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 RFQ. If any changes occur with respect to Proposer’s status regarding conflict of interest, Proposer shall promptly notify the State in writing.

Proposer certifies that all contents of the Proposal (including any other forms or documentation, if required under this RFQ) and this Proposal Certification Sheet, are truthful and accurate and have been prepared independently from all other Proposers, and without collusion, fraud, or other dishonesty.

Proposer understands that any statement or representation it makes, in response to this RFQ, 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.

Proposer acknowledges these certifications are in addition to any certifications required in the Contract awarded thereunder as of the Effective Date.

(Print Name and Title)

Contact Person for Questions / Contract Negotiations

Title:

Address:

Phone:

Email Address:

Proposer Information

Date of incorporation:

Federal Tax ID number