Exhibit A _ Certification Form.docx
DOCX document 33 KB Posted
- Attached to
- CSU, J-445-DP, Space Science / Robotics Facility
- Solicitation number
- PE-47200-RFQ-2025-000000097
- Issued by
- Muscogee County, Georgia
About this file
This document is a Certification Form for a state government contract issued by the Board of Regents of Georgia, specifically related to a project at Gordon State College involving a Student Activity and Recreation Center (Project PPV-89-1201). The form requires a proposer to certify various legal and professional compliance statements, including verification that the company and its principals have not been convicted of crimes, suspended from government contracting, or defaulted on previous government contracts within the past five years.
The certification form authorizes the Board of Regents to independently verify all submitted information and warns that any material false statements or omissions could result in suspension, debarment from future contracts, contract rescission, and potential criminal prosecution under Georgia state law (O.C.G.A. 16-10-20) and federal statutes (18 U.S.C. 1001 or 1341). The document requires a notarized signature, indicating the serious legal implications of the statements made by the proposing firm. While specific financial details are not provided, the form emphasizes transparency, integrity, and legal compliance in the government procurement process.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Exhibit E _ Contractor Affidavit.docx | DOCX document | |
| Exhibit D _ DP Fee Proposal.doc | DOC document | |
| Exhibit C _ Project Team Composition Form.docx | DOCX document | |
| Exhibit F _ Proposers Disclosure Statement.doc | DOC document | |
| _J_445 CSU Space Science Robotics Facility DP.pdf | ||
| Egnyte Upload Instructions.pdf | ||
| Exhibit G _ 179D Allocation Agreement.doc | DOC document | |
| Exhibit B _ Certificate of Minority Form.docx | DOCX document |
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Text version
Exhibit A
CERTIFICATION FORM
I, _____________________________, being duly sworn, state that I am ______________________(title) of _______________________________(firm) and hereby duly certify that I have read and understand the information presented in the attached proposal and any enclosure and exhibits thereto.
I further certify that to the best of my knowledge the information given in response to the request for proposals is full, complete and truthful.
I further certify that the proposer and any principal employee of the proposer have not, in the immediately preceding five years, been convicted of any crime of moral turpitude or any felony offense, nor has had their professional license suspended, revoked or been subjected to disciplinary proceedings.
I further certify that the proposer has not, in the immediately preceding five years, been suspended or debarred from contracting with any federal, state or local government agency, and further, that the proposer is not now under consideration for suspension or debarment from any such agency.
I further certify that the proposer has not in the immediately preceding five years been defaulted in any federal, state or local government agency contract, and further, that the proposer is not now under any notice of intent to default on any such contract.
I acknowledge, agree and authorize, and certify that the proposer acknowledges, agrees and authorizes, that the Board of Regents may, by means that the Board of Regents deems appropriate, determine the accuracy and truth of the information provided by the proposer and that the Board of Regents or their agents may contact any individual or entity named in the Statement of Qualifications for the purpose of verifying the information supplied therein.
I acknowledge and agree that all of the information contained in the Statement of Qualifications is submitted for the express purpose of inducing the Owner to award a contract.
A material false statement or omission made in conjunction with this proposal is sufficient cause for suspension or debarment from further contracts, or denial of rescission of any contract entered into based upon this proposal thereby precluding the firm from doing business with, or performing work for, the State of Georgia. In addition, such false statement or omission may subject the person and entity making the proposal to criminal prosecution under the laws of the State of Georgia of the United States, including but not limited to O.C.G.A. §16-10-20, 18 U.S.C. §§1001 or 1341.
Signature Sworn and subscribed before me
This _____ day of ________, 20__.
NOTARY PUBLIC
NOTARY SEAL
My Commission Expires: _________________
Gordon State College PPV-89-1201, Student Activity & Rec Ctr., PM RFQ/RFP
File details come from the government source that posted it. Updated .