Attachment 2 - Self-Certification for Antimafia.pdf

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Attached to
Healthcare Environmental Cleaning and Linen Laundry Services
Solicitation number
W9114F25QA037
Issued by

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Attachment 2 is an Italian self-certification form for anti-mafia communications, which serves as a declaration of compliance with legal requirements. The document is a standard form (D.P.R. n. 445 del 28.12.2000) where an individual representing a company declares that they do not have any disqualifying conditions under Article 67 of Legislative Decree No. 159 of 06/09/2011. The form requires the declarant to provide personal details, company information, and includes a privacy consent statement for data collection and processing under Legislative Decree No. 196/2003. The form is designed to be completed by an authorized representative of a business, with space for signature and date, and is intended to certify the absence of mafia-related impediments to conducting business.

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ATTACHMENT 2

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 n.

Prov. di Via 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)

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