Attachment 18 Self-certification for Anti-mafia Communication.pdf

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Attached to
MAINTENANCE AND REPAIR SERVICE POTABLE AND FIRE WATER GRID AT DARBY MILITARY COMMUNITY (DMC)
Solicitation number
W912PF25QA087
Issued by

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Written by GovTribe AI ·

This document is a Self-certification for Antimafia Communication form related to Solicitation W912PF25ATBD. The form is an Italian-language self-declaration template that requires an individual to certify they are not subject to restrictions under Article 67 of Legislative Decree No. 159 of 06/09/2011. The form is designed for an individual representing a company to declare that they have no legal impediments or disqualifications, with an acknowledgment of potential penalties for false statements. The document includes fields for personal details, company information, and requires a signature, with a note about data protection under Italian law (D.Lgs. n. 196/2003).

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Attachment 10

Combined Synopsis Solicitation W912PF25ATBD

Self-cer fica on for An mafia communica on

Autocer ficazione della comunicazione an mafia

Dichiarazione sos tu va di cer ficazione (D.P.R. n. 445 del 28.12.2000)

Il/la so oscri o/a (nome e cognome) _______________________________ C.F._________________ nato/a

_______________________________ Prov. _________ il ______________ residente a

________________________ Prov. _____ in via/piazza ____________________

_______________________________ n. ____, in qualità di (carica ricoperta) ___________ dell’impresa (indicare la denominazione) _______________________________________________ C.F. __________________ avente la sede in _________________________ Prov. di __________ Via ___________________________ n. ______ consapevole delle sanzioni penali in caso di dichiarazioni false e della conseguente decadenza dai benefici eventualmente consegui (ai sensi degli ar . 75 e 76 D.P.R. 445/2000) so o la propria responsabilità che nei propri confron non sussistono le cause di divieto, di decadenza o di sospensione di cui all’art. 67 del D.lgs. n. 159 del 06/09/2011.

DICHIARA

Il/la so oscri o/a dichiara inoltre di essere informato/a, ai sensi del D.Lgs. n. 196/2003 (codice in materia di protezione di da personali) che i da personali raccol saranno tra a , anche con strumen informa ci, esclusivamente nell’ambito del procedimento per il quale la presente dichiarazione viene resa.

data firma leggibile del dichiarante (2)

File details come from the government source that posted it. Updated .