B08-Attachment 03_Self Certification for Antimafia Communication_.pdf
PDF 195 KB Posted
- Attached to
- TESTS AND CERTIFICATIONS OF LIGHTNING PROTECTION SYSTEMS Federal contract opportunity
- Solicitation number
- W912PF25QA072
About this file
This document is a Self-certification for Antimafia communication form (Autocertificazione della comunicazione antimafia), a standard Italian legal declaration. The form is designed for an individual to self-certify that they are not subject to anti-mafia restrictions, specifically declaring that no disqualifying causes exist under Article 67 of Legislative Decree No. 159 of 06/09/2011. The form requires the declarant to provide personal details including name, tax identification number, birthplace, residence, and their role in a company, while also acknowledging potential legal penalties for false statements. The declarant must also confirm understanding of personal data protection regulations under Legislative Decree No. 196/2003, indicating that collected personal information will be processed exclusively for the specific procedural context of the declaration.
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Text version
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 .