05_-_OMESFormCP004.pdf

OMES FORM CP 004 Rev. 08/2023 PAGE 1 OF 1

NOTE: A certification shall be included with any competitive bid and/or contract exceeding $25,000.00 submitted to the State for goods or services.

Agency Name: Agency #:

Supplier or Bidder Legal Name:

Solicitation or Purchase Order #:

SECTION I [74 O.S. § 85.22]:

A. For purposes of competitive bid or contract executed by the state for an acquisition in excess of the fair and reasonable acquisition threshold amount, I certify:,

1. I am the duly authorized agent of the above-named supplier or bidder, for the purpose of certifying the facts pertaining to the existence of collusion among and between bidders and suppliers and state officials or employees, as well as facts pertaining to the giving or offering of things of value to government personnel in return for special consideration in connection with the prospective acquisition.

2. I am fully aware of the facts and circumstances surrounding the acquisition or making of the bid to which this statement relates and have been personally and directly involved in the events leading to the acquisition or submission of such bid;

and

3. Neither the business entity that I represent in this certification nor anyone subject to the business entity’s direction or control has been a party:

a. to any collusion among bidders or suppliers in restraint of freedom of competition by agreement to bid or contract at a fixed price or to refrain from bidding or contracting,

b. to any collusion with any state official or employee as to quantity, quality or price in the prospective contract, or as to any other terms of such prospective contract, nor

c. to any discussions between bidders or suppliers and any state official concerning exchange of money or other thing of value for special consideration in connection with the prospective contract.

B. I certify, if awarded the contract, whether competitively bid or not, neither the business entity I represent nor anyone subject to the business entity’s direction or control has paid, given or donated or agreed to pay, give or donate to any officer or employee of this state any money or other thing of value, either directly or indirectly, in procuring the contract to which this statement relates.

SECTION II [74 O.S. § 85.42]:

For the purpose of a contract for services, the supplier also certifies that no person who has been involved in any manner in the development of this contract while employed by the State of Oklahoma shall be employed by the supplier to fulfill any of the services provided for under said contract.

SECTION III [74 O.S. § 582]:

For the purpose of a contract for goods or services, the supplier also certifies it is not currently engaged in a boycott of goods or services from Israel that constitutes an integral part of business conducted or sought to be conducted with the state.

SECTION IV [74 O.S. § 12005]:

For the purpose of a contract for goods or services, the supplier also certifies it is not currently engaged in a boycott of energy companies and will not boycott energy companies during the term of the contract.

SECTION V DEBARMENT, SUSPENSION OR OTHER RESPONSIBILITY MATTERS:

For the purpose of a contract for goods or services, the supplier certifies any debarment, suspension, indictments, convictions, civil judgments and terminated public contracts have been disclosed to the State Purchasing Director.

The undersigned, duly authorized agent for the above named bidder or supplier, by signing below acknowledges this certification statement is executed for the purposes of:

the competitive bid attached herewith and contract, if awarded to said supplier;

OR

the contract attached herewith, which was not competitively bid and awarded by the agency pursuant to applicable Oklahoma statutes.

Certification for Competitive Bid and/or Contract

Non-Collusion Certification

Oklahoma State Department of Health 34000

EV00000569

OMES FORM CP 004 Rev. 08/2023 PAGE 1 OF 1

Printed Name Title

Fax Number

Supplier Authorized Signature Certified This Date

Phone Number Email