B01-SOL_W912PF25QAIRE_Attachment10_Self Certification for Antimafia Communication.pdf

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Attached to
Air Emission Monitoring and Testing USAG Italy DMC
Solicitation number
W912PF25QAIRE
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This document is a Self-certification for Antimafia communication form for Solicitation W912PF25QAIRE, which is an Italian legal document related to a federal contract opportunity for air emission monitoring and testing at USAG Italy DMC. The form is a standard self-declaration template where an individual (representing a company) attests that they do not have any disqualifying connections to organized crime, in compliance with Italian legal requirements (D.P.R. n. 445 del 28.12.2000 and D.lgs. n. 159 del 06/09/2011). The form requires the declarant to provide personal and company details, and includes a privacy notice regarding the collection and processing of personal data under Italian data protection laws.

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Attachment 10

Combined Synopsis Solicitation W912PF25QAIRE

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 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.

DICHIARA

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 .