4-Debarment and Suspension Certification - Form.pdf
PDF 51 KB Posted
- Attached to
- Caustic Soda State and local contract opportunity
- Solicitation number
- WU-06-26
- Issued by
- Tyler County, Texas
About this file
This is a Debarment and Suspension Certification form required by the City of San Angelo, Texas Purchasing Division for vendor participation in the procurement of caustic soda (sodium hydroxide diaphragm) for the Water Production Plant. The certification requires prospective primary vendors to confirm that they and their principals are not presently debarred, suspended, proposed for disbarment, or voluntarily excluded from covered transactions by any Federal department or agency. Vendors must also attest that within the three-year period preceding the application, they have not been convicted of or had a civil judgment rendered against them for fraud, criminal offenses in connection with public transactions, violations of antitrust statutes, or crimes including embezzlement, theft, forgery, bribery, falsification or destruction of records, false statements, or receipt of stolen property. Additionally, vendors certify that they are not presently indicted or criminally or civilly charged with commission of any enumerated offenses and have not had one or more public transactions terminated for cause or default within the preceding three-year period.
The form requires an authorized agent of the prospective vendor to sign and date the certification, with the printed vendor name and title of the signatory required. Any prospective primary vendor unable to certify to all statements in the certification must attach a written explanation to their bid submission. The City of San Angelo Water Production Plant utilizes approximately 450 dry tons of caustic soda annually at a 50% solution concentration for potable water treatment purposes.
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Text version
CITY OF SAN ANGELO, TEXAS
PURCHASING DIVISION
72 West College Avenue, San Angelo, Texas 76903
325.657.4219 • sapurch@cosatx.us
CITY OF SAN ANGELO, TEXAS • DEBARMENT AND SUSPENSION CERTIFICATION
Debarment and Suspension Certification
(1) The prospective primary vendor certifies to the best of its knowledge and belief that it and its principals:
(a) Are not presently debarred, suspended, proposed for disbarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency;
(b) Have not within a three-year period preceding this application been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;
(c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State, or local) with commission of any of the offenses enumerated in paragraph (1)(b) of this certification; and
(d) Have not within a three-year period preceding this application had one or more public transactions (Federal, State, or local) terminated for cause or default.
(2) Where the prospective primary vendor is unable to certify to any of the statements in this certification, such prospective primary vendor shall attach an explanation to this bid.
AUTHORIZED AGENT • PLEASE PRINT
VENDOR
NAME TITLE
SIGNATURE
DATE
mailto:sapurch@cosatx.us
Debarment and Suspension Certification
File details come from the government source that posted it. Updated .