S-10000-00009665 - Attachment A Application and Certification form.pdf

RFA S-10000-00009665 (5859) v1 / l.thomas Page 1 of 4 Attachment A – Independent Hearings Officer

Attachment A “APPLICATION and CERTIFICATION”

For ODHS RFA S-10000-00009665 – Independent Hearings Officer Services

Applicant’s Name

Name of Applicant’s authorized representative (if different)

Applicant’s Address, including City, State and Zip Code

Applicant’s Phone Number

Applicant’s Fax Number (if applicable)

Applicant’s Email Address

Provide two (2) references from current or former clients, firms, or organizations for similar projects performed for any clients within the last 10 years. References must be able to verify the quality of previous related Work. The Agency may check to determine if references provided support Applicant’s ability to comply with the requirements of this RFA. The Agency may use references to obtain additional information, or verify any information needed. The Agency may contact any reference (submitted or not) to verify Applicant’s qualifications

Reference 1:

Organization Name

Telephone

Contact Person

Facsimile

Project Title (if appropriate)

Email

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Reference 2:

Organization Name

Telephone

Contact Person

Facsimile

Project Title (if appropriate)

Email

Any individual signing below hereby certifies they are the Applicant or an authorized representative of Applicant, and that:

1. Applicant understands and accepts the requirements of this RFA. By submitting an Application, Applicant agrees to be bound by the Contract terms and conditions in Attachment B “Sample Contract,” of this RFA, and as modified by any Addenda, except for those terms and conditions that ODHS has reserved for negotiation, as identified in the RFA.

2. Applicant acknowledges receipt of any and all Addenda to this RFA.

3. (Reserved)

4. If awarded a Contract, Applicant agrees to perform the scope of work and meet the performance standards set forth in the final negotiated scope of work of the Contract.

5. I have knowledge regarding Applicant’s payment of taxes and by signing below I hereby certify that, to the best of my knowledge, Applicant 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. Applicant does not discriminate in its employment practices with regard to race, creed, age, religious affiliation, gender, disability, sexual orientation, national origin. When awarding subcontracts, Applicant 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, Applicant has, or will have prior to contract execution, a written policy and practice, that meets 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. ODHS may not enter into a contract with an anticipated contract price of $150,000 or more with a Applicant 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.

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

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7. Applicant complies with ORS 652.220 and does not unlawfully discriminate against any of Applicant’s employees in the payment of wages or other compensation for work of comparable character on the basis of 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.

Contractor’s continuing compliance constitutes a material element of this Contract and a failure to comply constitutes a breach that entitles ODHS to terminate this Contract for cause.

Contractor may not prohibit any of Contractor’s employees from discussing the employee’s rate of wage, salary, benefits, or other compensation with another employee or another person. Contractor 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. Applicant is not engaged in the provision of broadband Internet access service, or if at any time Applicant is engaged in or may engage in the provision of broadband Internet access service Applicant 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 Contract.

9. Applicant and Applicant’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/

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

11. Applicant certifies that all contents of the Application (including any other forms or documentation, if required under this RFA) and this Application Certification Sheet are truthful and accurate and have been prepared independently from all other Applicants, and without collusion, fraud, or other dishonesty.

12. Applicant understands that any statement or representation it makes, in response to this RFA, 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.

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

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13. Applicant acknowledges these certifications are in addition to any certifications required in the Contract and Statement of Work at the time of Contract execution including but not limited to Criminal History Checks of Applicant and other associated providers of service and Key Persons.

Authorized Signature

Printed Name and Title

Date