Attachment H_Certification of Recall or Safety Issue_NX EQ Irrigation Systems for Endoscopy.docx

Attachment H Certification of Recall or Safety Issues Instructions to Quoters:

1. Complete all fields in the certification form.

2. Ensure that the form is signed by an authorized representative of the company.

3. Submit the completed form along with your quote.

Certification of No Outstanding Recalls or Safety Issues Solicitation Number: 36C10X26R0030 Requirement for: NX EQ Irrigation Systems for Endoscopy

Company Unique Entity Identifier (UEI): __________________________________________

Certification:

By signing below, I, the undersigned, certify on behalf of the company identified by the UEI above, the medical equipment quoted in response to the above-referenced solicitation:

1. Does not have any outstanding recalls.

2. Does not have any known safety issues.

3. Complies with all relevant regulations and standards for medical equipment.

4. Has been thoroughly checked for compliance with safety and performance standards.

I understand that any false or misleading information provided in this certification may result in disqualification from the solicitation process and other penalties as permitted by law.

Authorized Representative:

Name: __________________________________________ Title: __________________________________________ Signature: __________________________________________ Date: __________________________________________