6-Attachment D-Scrutinized Co Cert.pdf
PDF 185 KB Posted
- Attached to
- Vein Finder for HMC Oncology
- Solicitation number
- PROJ-26-045
- Issued by
- Volusia County, Florida
About this file
This is a vendor certification form required by Halifax Health, a Florida government entity, for participation in a procurement for a Vein Finder for HMC Oncology. The certification form requires vendors to provide company identification information, including vendor name, Federal Employer Identification Number (FEIN), authorized representative details, and contact information. Vendors must certify compliance with Florida Statutes sections 287.135 and 215.4725 regarding scrutinized companies and boycott restrictions.
The certification prohibits vendors from bidding on contracts of any amount if the company appears on the Scrutinized Companies that Boycott Israel List, is engaged in a boycott of Israel, or maintains business operations in Cuba or Syria. For contracts exceeding one million dollars ($1,000,000), additional restrictions apply, prohibiting bidding by companies listed on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List. By signing the certification, the authorized representative attests that the company is not on any restricted list and is not engaged in prohibited business activities. Halifax Health reserves the right to terminate any contract if a vendor is found to have submitted false certification or is subsequently placed on a restricted list. False certification may result in civil penalties, attorney's fees, and costs under Florida Statutes section 287.135.
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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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