4-05-Vendor Integrity and Financial Interest Disclosure.pdf

Vendor Integrity & Financial Interest Disclosure Form

Project Name: Purchase, Delivery and Installation of AV Upgrades for the Bucks County Public Safey Training Center

RFQ Number: PUR00226

Vendor Name: ________________________________________________________

Part I: Integrity Representations & Warranties

By signing this form, the undersigned authorized representative of the Vendor represents and warrants that, except as explained in an attached written statement, neither the Vendor nor any "Vendor Related Parties" (as defined in the RFQ’s Terms and Conditions) have, within the last five (5) years:

1. Been indicted or convicted of a crime involving moral turpitude or business honesty.

2. Been suspended, debarred, or disqualified by any governmental agency.

3. Had any business or professional license suspended or revoked.

4. Been subject to sanctions or findings of fact regarding fraud, bribery, bid-rigging, or embezzlement.

5. Been the subject of a criminal or civil anti-trust investigation.

Check one:

☐ I certify that the Vendor meets all representations above.

☐ I cannot certify the above and have attached a written explanation.

Part II: Disclosure of Financial Interest

In accordance with the Contractor Integrity Provisions, the Vendor must disclose if it has a Financial Interest (ownership of >5% or a management/officer position) in any other subgrantee, contractor, subcontractor, or supplier providing services or materials under this agreement.

Check one:

☐ NO FINANCIAL INTEREST. The Vendor and its Related Parties do not have a financial interest in any other entity providing services, labor, or material under this agreement.

☐ FINANCIAL INTEREST DISCLOSED. The Vendor has a financial interest in the following entities involved in this project:

Section 05 – Vendor Integrity and Financial Interest Disclosure AV Upgrades for the Bucks County Public Safey Training Center

Name of Entity Nature of Financial Interest (e.g. % ownership, officer title, etc.)

(Attach additional pages if necessary)

Signature

I hereby certify that the information provided above is true and correct to the best of my knowledge and that I am authorized to bind the Vendor to these provisions.

Authorized Signature: __________________________________________

Printed Name: _________________________________________________

Title: ____________________________________ Date: _______________

Section 05 – Vendor Integrity and Financial Interest Disclosure AV Upgrades for the Bucks County Public Safey Training Center