Attachment 4 Self Certification for Antimafia CommunicationTests on Fire Pumps.pdf
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- Solicitation number
- W912PF25QFIRE
About this file
This document is a Self-certification for Antimafia Communication form associated with Solicitation W912PF25QFIRE for Tests and Inspections on Fire Pumps in Italy's Darby Military Community. The form is a standardized Italian legal declaration where a company representative certifies that the organization does not have any disqualifying connections to organized crime, as defined under Article 67 of Legislative Decree 159/2011. The form requires the declarant to provide personal details, company information, and acknowledge potential legal consequences for false statements, while also consenting to personal data processing under privacy regulations.
The form is an attachment to a combined synopsis/solicitation for commercial services issued by the Department of the Army Materiel Command Army Contracting Command. The procurement is for fire pump testing and inspection services, classified under NAICS code 333912 for Air and Gas Compressors Manufacturing, with a Product Service Code of H143 for Quality Control of Pumps and Compressors. The contract is anticipated to be a single-award, non-personal service contract on a firm fixed-price basis, governed by Federal Acquisition Regulations (FAR) Parts 12 and 13, with the requirement subject to availability of funds.
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Text version
Attachment 4
Combined Synopsis Solicitation W912PF25QFIRE
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 .