4-Attachment D-Scrutinized Co Cert.pdf
PDF 185 KB Posted
- Attached to
- Haag-Streit BQ 900 LED Slit Lamp with Imaging
- Solicitation number
- PROJ-25-160A
- Issued by
- Volusia County, Florida
About this file
This is a Vendors Certification form regarding scrutinized companies required by Halifax Health, a Florida government entity, as part of the procurement process for a Haag-Streit BQ 900 LED Slit Lamp with Imaging. The certification document requires vendors to provide their business identification information, including company name, Federal Employer Identification Number (FEIN), authorized representative details, and contact information. Vendors must complete and sign the certification confirming their compliance with Florida statutory requirements regarding international business activities and boycotts.
The certification prohibits vendors from bidding on or entering into contracts with Halifax Health if they are listed on the Scrutinized Companies that Boycott Israel List or engaged in boycotts of Israel, regardless of contract value. For contracts valued at one million dollars or more, vendors are additionally prohibited if they appear on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, or if they conduct business operations in Cuba or Syria. Vendors must certify they are not on any of these lists and are not engaged in the prohibited activities. False certifications may result in civil penalties, attorney's fees, and costs, and Halifax Health reserves the right to terminate any resulting contract if a vendor is found to have submitted false information or subsequently placed on a scrutinized companies list or engaged in prohibited business operations.
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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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