1. List any convictions of any person, subsidiary or affiliate of the company arising out of obtaining or attempting to obtain a public or private contract or subcontract, or in the performance of the contract or subcontract.
2. List any convictions of any person, subsidiary, or affiliate of this company for offenses such as embezzlement, theft, fraudulent schemes, and the like or any other offenses indicating a lack of business integrity or business honesty which affects the responsibility of the contractor. (See procurement policy § 3-5-126 for types of offenses.)
3. List any convictions or civil judgments under state or federal antitrust statutes.
4. List any violations of contract provisions such as knowingly (without good cause) to perform, or unsatisfactory performance, in accordance with the specifications of a contract.
5. List any prior suspensions or debarments by any governmental agency.
6. List any contracts not completed on time.
7. List any penalties imposed for time delays and/or quality of materials and workmanship.
8. List any documented violations of federal or state labor laws, regulations, or standards, occupational safety and health rules.
I, ____________________________________, as _________________________________
Name of individual Title and Authority
Of_____________________________________________, declare under oath that
Company Name
the above statements, including any supplemental responses attached hereto, are true.
________________________________________
Signature
State of __________________________________
City of __________________________________
Subscribed and sworn to before me on this______________day of ___________________________
20______ by _________________________________representing him or herself to be
___________________________________of the company named herein.
__________________________________
Notary public
My Commission expires:
__________________________________
Residing at:
__________________________________
(Res. 2008-011, passed 2-19-2008)