4_ Attachment D - Proposer Certification Form.pdf
PDF 93 KB Posted
- Solicitation number
- 25-26-08
- Issued by
- Santa Clara County, San Francisco City, California
About this file
This document is a Proposer Certification Form for the City of Santa Clara, designed to be completed by potential vendors submitting a proposal for goods or services. The form requires proposers to certify several key representations, including no collusion with other proposers, not being currently disbarred or suspended from government transactions, and acknowledging that only specified deviations and exceptions will be accepted. Proposers must also confirm they did not receive unauthorized information during the solicitation period and have no conflicts of interest with city employees.
The certification form additionally mandates that proposers affirm their commitment to non-discrimination in employment, covering a comprehensive list of protected characteristics including race, sex, color, religion, national origin, age, disability, sexual orientation, gender identity, and veteran status. Proposers must certify the accuracy of their proposal information and indicate their business structure (individual, partnership, corporation, limited liability company, or joint venture). The form provides signature lines for authorized representatives to validate these representations, with the understanding that submission constitutes acknowledgment of having investigated all aspects of the solicitation and understanding its procedures and requirements.
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Text version
Proposer Certification Form Page 1 of 2
ATTACHMENT D
PROPOSER CERTIFICATION FORM
Proposing Firm Name:
Address:
Telephone:
Facsimile:
E-mail:
Contact person name and title:
PROPOSER REPRESENTATIONS
1. Proposer did not, in any way, collude, conspire or agree, directly or indirectly, with any person, firm, corporation or other Proposer in regard to the amount, terms, or conditions of this proposal.
2. Proposer additionally certifies that neither Proposer nor its principals are presently disbarred, suspended, proposed for disbarment, declared ineligible or voluntarily excluded from participation in this transaction by any federal department or agency, any California State agency, or any local governmental agency.
3. Proposer acknowledges that all requests for deviations, exceptions, and approved equals are enclosed herein and that only those deviations, exceptions, and approved equals included in the solicitation document or permitted by formal addenda are accepted by the City.
4. Proposer did not receive unauthorized information from any City staff member or City
Consultant during the solicitation period except as provided for in the solicitation package, formal addenda issued by the City, or the pre-proposal conference.
5. Proposer certifies that to the best of its knowledge, no City officer, employee or authorized representative has any financial interest in the business of Proposer and that no person associated with Proposer has any interest, direct or indirect, which could conflict with the faithful performance of the agreement. Proposer is familiar with the provisions of California Government Code section 87100 and following, and certifies that it does not know of any facts which would violate these code provisions. Proposer will advise City if a conflict arises.
6. As suppliers of goods or services to the City of Santa Clara, Proposer and individuals listed below certify that they do not discriminate in employment of any person because of race, sex, color, religion, religious creed, national origin, ancestry, age, gender, marital status, physical disability, mental disability, medical condition, genetic information, sexual orientation, gender expression, gender identity, military and veteran status, or ethnic background; and that they are in compliance with all Federal, State and local laws, directives and executive orders regarding nondiscrimination in employment.
Proposer Certification Form Page 2 of 2
7. Proposer hereby certifies that the information contained in the proposal and all accompanying documents is true and correct.
8. Please check the appropriate box below:
If the proposal is submitted by an individual, it shall be signed by him or her, and if he or she is doing business under a fictitious name, the proposal shall so state.
If the proposal is submitted by a partnership, the full names and addresses of all members and the address of the partnership, the full names and addresses of all members and the addresses of the partnership, the full names and addresses of all members and the address of the partnership shall be stated and the proposal shall be signed for all members by one or more members thereof.
If the proposal is submitted by a corporation, it shall be signed in the corporate name by an authorized officer or officers.
If the proposal is submitted by a limited liability company, it shall be signed in the corporate name by an authorized officer or officers.
If the proposal is submitted by a joint venture, the full names and addresses of all members of the joint venture shall be stated and it shall be signed by each individual.
By signing below, the submission of a proposal with all accompanying documents shall be deemed a representation and certification by the Proposer that they have investigated all aspects of the solicitation, that they are aware of the applicable facts pertaining to the solicitation process, its procedures and requirements, and that they have read and understand the solicitation.
Authorized Representative Name (print name):
Signature (sign name):
Authorized Representative Title (print title):
Complete additional signatures below as required per # 8 above
| ATTACHMENT D |
| PROPOSER CERTIFICATION FORM |
File details come from the government source that posted it. Updated .