B08-SOL_W912PF24Q0047_Attachment 1_Antimafia.pdf

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Custodial services at USAG-Italy Vicenza and Poggio Renatico (FE), Italy.
Solicitation number
W912PF24Q0047
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This document is an Autocertificazione della comunicazione antimafia, which is a substitute declaration for the anti-mafia communication required as part of a federal contract opportunity.

The document is related to Solicitation W912PF24Q0047 for custodial services at USAG-Italy Vicenza and Poggio Renatico (FE), Italy, issued by the Department of the Army Materiel Command Army Contracting Command. This substitute declaration requires the contractor to certify that there are no grounds for prohibition, forfeiture, or suspension under Article 67 of Legislative Decree No. 159 of 6 September 2011. The contractor must provide this declaration under their own responsibility and is informed that the personal data collected will be processed, including electronically, solely within the scope of the procedure for which this declaration is made.

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W912PF24Q0047

ATTACHMENT 1

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 n.

Prov. di Via 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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