7101123106Certificate.pdf

Group 71011 - Security Guard Services (Statewide) and Fire Safety/EAP Directors (Region 1 - NYC only) Page 1 of 1

7101123106_CertofCompliance113018

Attachment 5 - Certificate of Compliance

(To be filed with the Authorized User and a copy maintained by Contractor)

I, ____________________________, have reviewed all of the terms and conditions of the New York State Office of General

Services’ Security Guard and Fire Safety/EAP Directors Contract with a Contract Number of __________________ as well as the Request for Quotes (RFQ) issued by _________________________________ (Authorized User Name) for the Facility with an address of _____________________________ prior to assigning and/or directing a Security Guard and/or Fire Safety/EAP

Director to provide services at the specified Level thereunder.

I certify, under the penalty of perjury, that the Security Guard and/or Fire Safety/EAP Director with the name of

____________________, NYS Department of State Registration No.____________ Issue Date________ and/or NYC Fire

Department Certificate of Fitness Date _________________ meets all of the qualifications required for the position of a Level I, Level II, Fire Safety/EAP Director (CIRCLE ONE) as requested by the Authorized User in its RFQ dated _____________ for assignment at the Facility with the name of_____________________, and also meets the requirements as set forth in the above-referenced OGS Security Guard and Fire Safety/EAP Director Contract.

Dated: ___________________________

Printed Name _________________________________

Signature _____________________________________

Contractor _____________________________________

(☐ If a corporation): _he is the ____________________________________of____________________________, the corporation described in said instrument; that, by authority of the Board of Directors of said corporation, _he is authorized to execute the foregoing instrument on behalf of the corporation for purposes set forth therein; and that, pursuant to that authority, _he executed the foregoing instrument in the name of and on behalf of said corporation as the act and deed of said corporation.

(☐ If a partnership): _he is the ____________________________________of____________________________, the partnership described in said instrument; that, by the terms of said partnership, _he is authorized to execute the foregoing instrument on behalf of the partnership for purposes set forth therein; and that, pursuant to that authority, _he executed the foregoing instrument in the name of and on behalf of said partnership as the act and deed of said partnership.

(☐ If a limited liability company): _he is a duly authorized member of ___________________________, LLC, the limited liability company described in said instrument; that _he is authorized to execute the foregoing instrument on behalf of the limited liability company for purposes set forth therein; and that, pursuant to that authority, _he executed the foregoing instrument in the name of and on behalf of said limited liability company as the act and deed of said limited liability company.

Signed this

______day of___________, 20__

Notary Public Name: __________________________________

State: ____________________________

New York State Notary Number: _____________________________