Biolytical Labs Attachment D.pdf

ATTACHMENT D

PARTICIPATION IF BOYCOTT OF ISRAEL FORM ARIZONA DEPARTMENT OF

HEALTH SERVICES

150 North 18th Avenue, Suite 530

Phoenix, AZ 85007

INVITATION FOR BID NO.: BPM006041

RAPID HIV TEST KITS

FOR COMMUNITY BASED TESTING EVENTS

Please note that if any of the following apply to this Solicitation, Contract, or Contractor, then the Offeror shall select the “Exempt Solicitation, Contract, or Contractor” option below:

• The Solicitation or Contract has an estimated value of less than $100,000;

• Contractor is a sole proprietorship;

• Contractor has fewer than ten (10) employees; OR

• Contractor is a non-profit organization.

Pursuant to A.R.S. §35-393.01, public entities are prohibited from entering into contracts “unless the contract includes a written certification that the company is not currently engaged in, and agrees for the duration of the contract to not engage in, a boycott of goods or services from Israel.”

Under A.R.S. §35-393:

1. "Boycott" means engaging in a refusal to deal, terminating business activities or performing other actions that are intended to limit commercial relations with entities doing business in Israel or in territories controlled by Israel, if those actions are taken either:

(a) Based in part on the fact that the entity does business in Israel or in territories controlled by Israel.

(b) In a manner that discriminates on the basis of nationality, national origin or religion and that is not based on a valid business reason.

2. "Company" means an organization, association, corporation, partnership, joint venture, limited partnership, limited liability partnership, limited liability company, or other entity or business association, including a wholly-owned subsidiary, majority-owned subsidiary, parent company or affiliate, that engages in for-profit activity and that has ten or more full-time employees.

3. "Public entity" means this State, a political subdivision of this State or an agency, board, commission or department of this State or a political subdivision of this State.

The certification below does not include boycotts prohibited by 50 United States Code Section 4842 or a regulation issued pursuant to that section. See A.R.S. §35-393.03.

In compliance with A.R.S. §§35-393 et seq., all offerors must select one of the following:

X The Company submitting this Offer does not participate in, and agrees not to participate in during the term of the contract, a boycott of Israel in accordance with A.R.S. §§35-393 et seq. I understand that my entire response will become public record in accordance with A.A.C. R2-7-C317.

The Company submitting this Offer does participate in a boycott of Israel as described in A.R.S. §§35-393 et seq.

Exempt Solicitation, Contract, or Contractor.

Indicate which of the following statements applies to this Contract:

Solicitation or Contract has an estimated value of less than $100,000;

Contractor is a sole proprietorship;

Contractor has fewer than ten (10) employees; and/or Contractor is a non-profit organization.

Company Name Signature of Person Authorized to Sign

Address Printed Name

City State Zip Title bioLytical Laboratories

13251 Delf Pl Brandon Carlson

Account Manager

BrandonCarlson

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