5-Scrutinized Companies Form.pdf
PDF 600 KB Posted
- Attached to
- Automotive Batteries
- Solicitation number
- RFB No. 2026-033
- Issued by
- Palm Beach County, Florida
About this file
This is a Scrutinized Company Certification form required by the Town of Palm Beach, Florida for vendors participating in the Automotive Batteries solicitation. The form serves as a compliance document wherein vendors must certify their company's status regarding participation in boycotts of Israel, involvement in Sudan-related business activities, investments in Iran's petroleum sector, and business operations in Cuba or Syria. The vendor must complete the form by providing company name, signatory information, title, and date, along with sworn affirmation that the company does not appear on any scrutinized companies lists as established pursuant to Florida Statutes 215.4725, 215.473, and 287.135. The certification is mandatory for bid submission and is processed through the Town of Palm Beach Purchasing Division located at 951 Okeechobee Road, Suite D, West Palm Beach, Florida 33401.
The form requires vendors to affirm compliance with four primary conditions: non-participation in Israel boycotts, absence from Sudan-related business activities lists, absence from Iran petroleum sector investment lists, and no active business operations in Cuba or Syria. Failure to properly complete and submit this certification, or misrepresentation of company status, may result in bid rejection. The certification is dated November 16, 2018, and references specific Florida statutes that govern vendor eligibility for state and local contract opportunities. This documentation is a prerequisite compliance step in the competitive bidding process for automotive battery supplies.
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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 .