5-Scrutinized Companies Form.pdf
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- Attached to
- Prequalification of Roofing Contractors
- Solicitation number
- RFQ No. 2025-029
- Issued by
- Palm Beach County, Florida
About this file
This is a Scrutinized Company Certification form issued by the Town of Palm Beach Purchasing Division located at 951 Okeechobee Road Suite D, West Palm Beach, Florida 33401. The form is dated 11/16/18 and serves as a mandatory compliance document that vendors must complete and submit as part of the procurement process, certifying their company's status regarding various prohibited business activities under Florida Statutes 215.4725, 215.473, and 287.135.
The certification requires vendors to affirm under oath that their company is not participating in boycotts of Israel, does not appear on scrutinized companies lists related to activities in Sudan or Iran's petroleum energy sector, and is not engaged in business operations in Cuba or Syria. The form includes specific criteria for each prohibited activity, such as having material business relationships with certain governments, involvement in oil or mineral extraction activities, supply of military equipment, or complicity in genocidal campaigns. Vendors must provide their company name, authorized signatory's name and title, signature, and date to complete the certification, with blank fields provided for this information at the bottom of the form.
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Text version
11/16/18
Scrutinized Company Certification
1. This company is not participating in a boycott of Israel such that it is not refusing to deal, terminating business activities, or taking other actions to limit commercial relations with Israel, or persons or entities doing business in Israel or in Israeli-controlled territories, in a discriminatory manner.
2. This Company does not appear on the Scrutinized Companies with Activities in Sudan List where the
State Board of Administration has established the following criteria:
a. Have a material business relationship with the government of Sudan or a government-created project involving oil related, mineral extraction, or power generation activities, or
b. Have a material business relationship involving the supply of military equipment, or
c. Impart minimal benefit to disadvantaged citizens that are typically located in the geographic periphery of Sudan, or
d. Have been complicit in the genocidal campaign in Darfur.
3. This Company does not appear on the Scrutinized Companies with Activities in the Iran Petroleum
Energy Sector List where the State Board of Administration has established the following criteria:
a. Have a material business relationship with the government of Iran or a government-created project involving oil related or mineral extraction activities, or
b. Have made material investments with the effect of significantly enhancing Iran‘s petroleum sector.
4. This Company is not engaged in business operations in Cuba or Syria.
VENDOR/COMPANY NAME:
NAME:
TITLE:
SIGNATURE:
DATE:
TOWN OF PALM BEACH
PURCHASING DIVISION
951 Okeechobee Road Suite D West Palm Beach, Florida 33401
Telephone: (561) 838-5406
PURCHASING DIVISION
951 Okeechobee Road Suite D West Palm Beach, Florida 33401
Telephone: (561) 838-5406 Facsimile (561) 835-4688 Website: www.townofpalmbeach.com
I hereby swear or affirm that as of the date below this company is not listed on a Scrutinized Companies list created pursuant to 215.4725, 215.473, or 287.135, Florida Statutes. Pursuant to 287.135, Florida Statutes I further affirm that:
http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0200-0299/0215/Sections/0215.4725.html http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0200-0299/0215/Sections/0215.4725.html http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0200-0299/0287/Sections/0287.135.html
| VENDORCOMPANY NAME: |
| Name: |
| Title: |
| Signiture: |
| Date: |
File details come from the government source that posted it. Updated .