Attachment 5 Antimafia Self Certification.pdf

PDF 204 KB Posted

Attached to
BASE WIDE WI-FI AVIANO AIR BASE ITALY
Solicitation number
FA568223Q0021
Issued by

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Written by GovTribe AI ·

This document is an antimafia self-certification form required for a federal contract opportunity to provide BASE WIDE WI-FI services at Aviano Air Base in Italy. The opportunity is solicitation number FA568223Q0021 issued by the Department of the Air Force United States Air Forces in Europe - Air Forces Africa. The self-certification form requires the contractor to attest that they are not subject to any prohibitions, decertification, or suspension under Article 67 of Italian Legislative Decree 159/2011. By signing the form, the contractor acknowledges they understand their personal data will be processed and stored electronically solely for the purpose of the procurement.

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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)

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