2-BPM006391 Attac E Forced Labor Dup Kupplin.pdf

Attachment E

Forced Labor of Ethnic Uyghurs Ban

ARIZONA DEPARTMENT OF

HEALTH SERVICES

150 North 18th Avenue, Suite 530

Phoenix, AZ 85007 Solicitation No.: BPM006391

PAGE

Description: REGISTRY STAFFING FOR THE

ARIZONA STATE HOSPITAL

OF

SPO Form 205 – Forced Labor of Ethnic Uyghurs Ban | Revision No. 1 | Revised 09-22

Forced Labor of Ethnic Uyghurs Ban

Please note that if any of the following apply to the Contractor, then the Offeror shall select the “Exempt

Contractor” option below:

● Contractor is a sole proprietorship;

● Contractor has fewer than ten (10) employees; OR

● Contractor is a non-profit organization.

Pursuant to A.R.S. § 35-394, written certification is required to show that the company entering into a contract with a public entity does not use the forced labor, or any goods or services produced by the forced labor, of ethnic Uyghurs in the People's Republic of China.

Under A.R.S. § 35-394:

1. "Company" means an organization, association, corporation, partnership, joint venture, limited partnership, limited liability partnership, limited liability company or other entity or business association, including a wholly owned subsidiary, majority-owned subsidiary, parent company or affiliate, that engages in for-profit activity and that has ten or more full-time employees.

2. "Public entity" means this State, a political subdivision of this State or an agency, board, commission or department of this State or a political subdivision of this State.

In compliance with A.R.S. §§ 35-394 et seq., all offerors must select one of the following:

☐ The Company submitting this Offer does not use, and agrees not to use during the term of the contract, any of the following:

● Forced labor of ethnic Uyghurs in the People’s Republic of China;

● Any goods or services produced by the forced labor of ethnic Uyghurs in the People’s Republic of

China; or

● Any Contractors, Subcontractors, or suppliers that use the forced labor or any goods or services produced by the forced labor of ethnic Uyghurs in the People’s Republic of China.

☐ The Company submitting this Offer does participate in use of Forced Uyghurs Labor as described in A.R.S. §

35-394.

☐ Exempt Contractor

Indicate which of the following statements applies to the Contractor (may be more than one):

☐ Contractor is a sole proprietorship;

☐ Contractor has fewer than ten (10) employees; and/or

☐ Contractor is a non-profit organization.

Company Name Signature of person authorized to sign

Address Printed name and title

City, State, ZIP Contact email address Contact phone number

Dell Typewritten text Kupplin Worldwide, LLC

Dell Typewritten text 8870 Business Park Dr. Ste. 200

Dell Typewritten text Austin, TX 78759

Dell Typewritten text Anila Moledina

Dell Typewritten text anilamoledina@kupplin.com

Dell Typewritten text , 512-300-1478

Dell Typewritten text N/A

Dell Typewritten text

, CEO

Dell Typewritten text X