4-Attachment D-Scrutinized Co Cert.pdf
PDF 185 KB Posted
- Attached to
- Recumbent Cross Trainer
- Solicitation number
- PROJ-26-023
- Issued by
- Volusia County, Florida
About this file
This is a Vendor Certification form regarding Scrutinized Companies, issued by Halifax Health in Florida, that vendors must complete and submit as part of the procurement process for equipment and services. The certification pertains to a contract opportunity for three (3) NuStep T5XR Recumbent Cross Trainers, including full-service delivery to Halifax Health Medical Center in Daytona Beach, Florida. Vendors must provide their company name, Federal Employer Identification Number (FEIN), authorized representative information, business address, telephone number, and email address on the form.
The form requires vendors to certify compliance with Florida Statutes Section 287.135 and Section 215.4725, confirming that their company is not listed on the Scrutinized Companies that Boycott Israel List, the Scrutinized Companies with Activities in Sudan List, or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List. Additionally, vendors must certify that their company is not engaged in a boycott of Israel or business operations in Cuba or Syria. The certification must be signed by an authorized representative under penalty of perjury. False certifications may result in civil penalties, attorney's fees, and contract termination. For contracts valued at one million dollars or more, additional grounds for termination apply regarding Sudan, Iran, Cuba, and Syria activities.
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Text version
Attachment D
VENDORS CERTIFICATION REGARDING SCRUTINIZED COMPANIES
Vendor Name: ________________________________________________________________
Vendor FEIN: __________________________________
Vendors Authorized Representative Name and Title: ___________________________________
Address: _____________________________________________________________________
City: ___________________________________ State: ___________ Zip: ______________
Telephone Number: ____________________________
Email Address: ________________________________________________________________
Section 287.135(2)(a), Florida Statutes, prohibits a company from bidding on, submitting a proposal for, or entering into or renewing a contract for goods or services of any amount if, at the time of contracting or renewal, the company is on the Scrutinized Companies that Boycott Israel List, created pursuant to § 215.4725, Florida Statutes, or is engaged in a boycott of Israel.
Section 287.135(2)(b), Florida Statutes, further prohibits a company from bidding on, submitting a proposal for, or entering into or renewing a contract for goods or services over one million dollars ($1,000,000) if, at the time of contracting or renewal, the company is on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, both created pursuant to § 215.473, Florida Statutes, or the company is engaged in business operations in Cuba or Syria.
As the person authorized to sign on behalf of the Vendor, I hereby certify that the company identified in the Section entitled “Vendor Name” above is not listed on any of the following: (i) the Scrutinized Companies that Boycott Israel List, (ii) Scrutinized Companies with Activities in Sudan List, or (iii) the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List. I further hereby certify that the company identified above is not engaged in a boycott of Israel or engaged in business operations in Cuba or Syria. I understand that pursuant to § 287.135, Florida Statutes, the submission of a false certification may subject the company to civil penalties, attorney’s fees, and/or costs. I further understand that any contract with Halifax Health for goods or services of any amount may be terminated at the option of Halifax Health if the company (i) is found to have submitted a false certification, (ii) has been placed on the Scrutinized Companies that Boycott Israel List, or (iii) is engaged in a boycott of Israel. And, in addition to the foregoing, if the amount of the contract is one million dollars ($1,000,000) or more, the contract may be terminated at the option of Halifax Health if the company is found to have submitted a false certification, has been placed on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, or has been engaged in business operations in Cuba or Syria.
Signature of Authorized Representative: ___________________________________________
Printed Name: _____________________________________________ Date:_____________
Title of Authorized Representative: ________________________________________________
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