3-C-DFCM Termination Debarment Certification Form 8.9.2024.pdf
PDF 667 KB Posted
- Solicitation number
- MP27008
- Issued by
- Utah
About this file
This file is a Termination or Debarment Certification Form from the State of Utah Department of Public Licensing (DOPL), revised August 9, 2024, which applies to the DFCM Construction - VBS Consultant Services for Programming & Design services related to the UDOT Cottonwood Canyons Transit Stations project valued at $19,100,000.00. The form requires a firm's authorized representative to certify that neither the firm nor its principals are currently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from soliciting work by any government agency. The certification also confirms that the firm and its principals have not been terminated during contract performance or withdrawn from a contract to avoid termination.
If a firm is unable to certify compliance with the stated conditions, the form provides space for an explanation of circumstances. The form requires completion of standard fields including firm name, DPL number if applicable, signature, printed name, title, and date. This certification document is a prerequisite compliance requirement for firms bidding on the Cottonwood Canyons Transit Stations project, which involves substantial improvements at two resort bus stops located at Solitude Ski Resort and Brighton Ski Resort.
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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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| Name: |
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| Title: |
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| Date: |
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| DOPL: |
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Explanation:
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