Attachment 2 Self Certification for Antimafia Communication.pdf
PDF 346 KB Posted
- Attached to
- Tests and Inspections of Fire Extinguishers, Fire Rated Doors and Panic Hardware at USAG Italy DMC
- Solicitation number
- W912PF26QA041
About this file
This document is a self-certification form for antimafia communication required as Attachment 2 to Request for Quotation W912PF26QA041. The form is a declarative certification template issued under Italian law (D.P.R. n. 445 del 28.12.2000) and is bilingual in Italian and English.
The form requires the signatory to provide personal identification information including full name, tax identification number (C.F.), date and place of birth, and residence address, as well as the company name, tax identification number, and registered office address. The declarant must attest under penalty of false statements that they and their company have no disqualifying factors, suspension, or prohibition issues as defined under Article 67 of Legislative Decree 159/2011 (D.Lgs. n. 159 del 06/09/2011). The form also includes a data privacy notice informing the declarant that personal data collected will be processed exclusively for the procurement procedure in question, in accordance with Italian data protection law (D.Lgs. n. 196/2003). The completed certification must be signed and dated by the declarant with a legible signature. This is a standard compliance document template rather than a solicitation containing specific products or services requirements.
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Other files
| File | Type | Posted |
|---|---|---|
| Attachment1 Fire Extinguishers Inventory.xls | XLS spreadsheet | |
| Attachment 5 Hazard General List.pdf | ||
| Attachment 4 Standard Operating Procedures.pdf | ||
| Attachment 6 Performance Work Statement.pdf | ||
| Attachment 3 DUVRI.pdf | ||
| Attachment 7 Experience Questionnaire.docx | DOCX document |
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Text version
Attachment 2
Request for Quotation W912PF26QA041
Self-certification for Antimafia communication
Autocertificazione della comunicazione antimafia
Dichiarazione sostitutiva di certificazione (D.P.R. n. 445 del 28.12.2000)
Il/la sottoscritto/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 conseguiti (ai sensi degli artt. 75 e 76 D.P.R. 445/2000) sotto la propria responsabilità
DICHIARA
che nei propri confronti 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.
Il/la sottoscritto/a dichiara inoltre di essere informato/a, ai sensi del D.Lgs. n. 196/2003 (codice in materia di protezione di dati personali) che i dati personali raccolti saranno trattati, anche con strumenti informatici, 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 .