Attachment A - Exhibit A-3-a.docx
DOCX document 53 KB Posted
- Solicitation number
- RFP-16336
- Issued by
- Leon County, Florida
About this file
This is a Vendor Certification Form (Form PUR 7801) required by the State of Florida, Agency for Health Care Administration (AHCA) for RFP 015-25/26 related to the Organ and Tissue Donor Registry and Education Program. The form establishes mandatory compliance certifications that vendors must complete and submit prior to contract award. Key certifications include attestations that the vendor is not participating in boycotts of Israel, is not on state scrutinized company lists, is not on the Suspended Vendor List or Convicted Vendor lists, has completed required E-Verify registration for newly hired employees, maintains compliance with all applicable disclosure requirements, and has not had any contracts terminated for E-Verify violations within the past year. For contracts valued at $1 million or more, vendors must additionally certify they are not on the Scrutinized Companies with Activities in Sudan or Iran Terrorism Sectors lists and have no business operations in Cuba or Syria.
Additional certifications address specific contract conditions and vendor status. If the contract grants access to personal identifying information, the vendor must complete and submit Form PUR 1355 (Foreign Country of Concern Attestation Form). For common carriers or contracted carriers, Form PUR 1808 must be completed and submitted. If the contract involves non-governmental and governmental entity relationships, vendors must complete Form PUR 2024, Part A regarding coercion for labor and services. For commodity provision contracts, vendors must submit Form PUR 2024, Part B certifying that commodities have not been produced by forced labor and must not have been placed on the Forced Vendor List within the past 365 days. The form requires signature by an authorized vendor representative and includes fields for company name, FEIN, signatory name, title, and date of certification.
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Other files
| File | Type | Posted |
|---|---|---|
| Attachment A - Exhibit A-5.docx | DOCX document | |
| Attachment A - Exhibit A-4.docx | DOCX document | |
| Attachment A - Exhibit A-9.docx | DOCX document | |
| AHCA RFQ 015-2526_Addendum No. 3.pdf | ||
| Attachment A - Exhibit A-7.xlsx | XLSX spreadsheet | |
| Attachment A - Exhibit A-8.doc | DOC document | |
| Attachment A - Exhibit A-6.xlsx | XLSX spreadsheet | |
| Attachment A - Exhibit A-2.docx | DOCX document | |
| AHCA RFP 015-2526 Organ and Tissue Donor.pdf | ||
| AHCA RFP 015-2526 - Addendum No. 1.pdf | ||
| AHCA RFQ 015-2526_Addendum No. 2.pdf | ||
| Attachment A - Exhibit A-3.docx | DOCX document | |
| Attachment A - Exhibit A-1.xlsx | XLSX spreadsheet | |
| Attachment A - Exhibit A-10.pdf |
Show all 14
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Text version
RFP 015-25/26, EXHIBIT A-3-a
VENDOR CERTIFICATION FORM
I hereby certify the following on behalf of the vendor identified below:
| Customer Indicator (Required, N/A, Determined by Vendor) |
| Vendor Indicator (Certified, N/A) |
| Certification |
| Required | |
| Certified | Regardless of the dollar value of the goods or services provided, in accordance with the requirements of section 287.135(5), F.S., the vendor is not participating in a boycott of Israel and is not on the State Board of Administration’s “Quarterly List of Scrutinized Companies that Boycott Israel,” available at https://www.sbafla.com/governance/global-governance-mandates/ |
| Required | |
| Certified | If the goods or services to be provided are $1 million or more, in accordance with the requirements of section 287.135, F.S., the vendor is not on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Terrorism Sectors List (collectively, “Scrutinized List of Prohibited Companies”); does not have business operations in Cuba or Syria; and is not on the State Board of Administration’s “Scrutinized List of Prohibited Companies” available under the quarterly reports section at https://www.sbafla.com/reporting/ |
| Required | |
| Certified | The vendor is not on the Suspended Vendor List; it and its suppliers, subcontractors, or consultants to be utilized under the contract are not on the Convicted Vendor, Discriminatory Vendor, or Antitrust Violator Vendor Lists; and there is no pending or threatened action, proceeding, or investigation, or any other legal or financial condition, that would in any way prohibit, restrain, or diminish the vendor’s ability to satisfy the contract obligations. |
The vendor is hereby informed of the provisions of sections 287.133(2)(a), 287.134(2)(a), and 287.137(2)(a), F.S., that identify the impacts to the vendor's ability or its affiliates’ ability to respond to the competitive solicitations of a public entity; to be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a contract with a public entity; or to transact business with a public entity if it, or its affiliates, are placed on the Convicted Vendor, Discriminatory Vendor, or Antitrust Violator Vendor Lists of the Department of Management Services. The vendor is hereby further informed of the provisions of section 287.1351, F.S., that identify the impacts to the vendor’s ability to enter into or renew a contract with an agency, as defined in section 287.012, F.S., if it is placed on the Suspended Vendor List of the Department of Management Services.
| Required | |
| Certified | If the contract grants the vendor access to an individual’s personal identifying information, the vendor is not prohibited from entering into the contract pursuant to section 287.138, F.S., and has completed the Form PUR 1355, “Foreign Country of Concern Attestation Form,” available at http://www.flrules.org/Gateway/reference.asp?No=Ref-15843, and submitted it to the Agency. |
| N/A | |
| N/A | If the vendor is a common carrier, as defined in section 908.111, F.S., or a contracted carrier, it is not prohibited from entering into the contract pursuant to section 908.111, F.S., and has completed the Form PUR 1808, “Common Carrier or Contracted Carrier Attestation Form,” available at http://www.flrules.org/Gateway/reference.asp?No=Ref-14614, and submitted it to the Agency. |
| Required | |
| Certified | The vendor is registered with, and uses, the E-Verify system for all newly hired employees in accordance with section 448.095, F.S.; and has not, within the last year, had a contract terminated under section 448.095(5)(c), F.S., by a public employer, contractor, or subcontractor, as defined by section 448.095(1), F.S. |
| Required | |
| Certified | The vendor is in compliance with all applicable disclosure requirements set forth in section 286.101, F.S., and has not been deemed ineligible for a grant or contract funded by a state agency pursuant to section 286.101(7), F.S. |
| Required | |
| Certified | If the contract is between a nongovernmental entity and a governmental entity, in accordance with section 787.06, F.S., the vendor has completed an affidavit signed by an officer or a representative of the vendor under penalty of perjury attesting that the vendor does not use coercion for labor or services as defined in section 787.06, F.S. |
To fulfill this requirement, the vendor has completed Form PUR 2024, “Part A: Use of Coercion for Labor and Services,” and submitted it to the Agency.
| N/A | |
| N/A | If the Contract is for the provision of commodities, in accordance with section 287.1346, F.S., the vendor, and any entity under the control of vendor, has not been placed on the Forced Vendor List within the past 365 days or, if placed on the Forced Vendor List, has been removed pursuant to section 287.1346(5)(d), F.S. |
If the Contract is for the provision of commodities, the Contractor will submit, prior to entering into or renewing the Contract, a written certification from senior management, as defined in section 287.1346(1)(c), F.S., which certifies to the best of their knowledge the commodities being offered pursuant to this solicitation have not been produced, in whole or in part, by forced labor.
To fulfill this requirement, the vendor has completed Form PUR 2024, “Part B: Provision of Commodities Produced by Forced Labor,” and submitted it to the Agency.
The vendor is hereby informed of the provisions of section 287.1346, F.S., that identify the impacts to a vendor’s ability to respond to the competitive solicitations of a state agency; to be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a contract with a state agency; or to transact business for the provision of commodities with a state agency if it, or entities under the control of the vendor, is placed on the forced labor list in accordance with section 287.1346, F.S.
By signing below, I certify that I am authorized to complete and submit this Vendor Certification Form on behalf of the vendor.
Vendor Information Signatory
Company Name Signature Date
FEIN Typed or Printed Name
Title
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK
Form PUR 7801 (07/2024)
AHCA (10/24)
Rule 60A-1.002, F.A.C.
File details come from the government source that posted it. Updated .