Carroll_Branch_Affirmation_and_Disclosure_Form.pdf

This document is an Affirmation and Disclosure Form for a contract involving Company Western Ltd., specifically related to the Ohio Department of Transportation (ODOT) and its Executive Order 2022-02D concerning restrictions on services from Russian companies or institutions. The form details the contractor's principal business location at 4805 Scurry Lane in Carroll, OH 43112, and affirms compliance with state data handling requirements and restrictions on performing services related to Russian entities.

The form emphasizes the contractor's agreement to abide by Executive Order 2022-02D, which prohibits the purchase of services from Russian companies or institutions. The document requires disclosure of business locations, service performance locations, and state data storage locations, all of which are listed as 4805 Scurry Lane in Carroll, OH. The contractor, represented by Charles D Clark in the role of Midwest Regional Sales Manager, signed the document on 1-8-25, affirming no services will be performed in Russia and acknowledging ODOT's right to terminate the contract if there are any changes in service locations or violations of the executive order.