3-C-DFCM Termination Debarment Certification Form 8.9.2024.pdf
PDF 667 KB Posted
- Solicitation number
- DA27015
- Issued by
- Cache County, Utah
About this file
This is a Termination or Debarment Certification Form issued by the State of Utah Department of Public Licensing (DOPL) for use in conjunction with DFCM construction contracting. The form requires firms and their principals to certify that they are not currently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from soliciting work by any government agency. Additionally, the certification confirms that neither the firm nor its principals have been terminated during the performance of a contract or withdrawn from a contract to avoid termination. The form requires the signature of an authorized representative along with printed name, title, and date of certification.
If a firm cannot certify to the above statement, the form provides space for an explanation of the circumstances that prevent compliance with the debarment and termination requirements. This certification is required for all special inspection contractors, material testing labs, and special inspectors seeking to work on DFCM projects, including the Utah State University Animal Science Renovation and Expansion project with an estimated inspections budget of $192,438.00.
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Text version
DFCM Termination or Debarment Certification Form, Revised 8.9.2024
Termination or Debarment Certification Form
Firm Name:
State of Utah Department of Public Licensing Number, if applicable:
The signature below certifies that the referenced firm nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or are voluntarily excluded from soliciting work by any government agency. This form also certifies that neither they nor their principals have been terminated during the performance of a contract or withdrew from a contract to avoid termination.
Signature:
Name:
Title:
Date:
If the firm cannot certify to the statement above, please provide an explanation of the circumstances below.
Signature:
Name:
Title:
Date:
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Explanation:
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