Exhibit A _ Certification Form.docx
DOCX document 34 KB Posted
- Attached to
- GSOU J-460-DP School of Optometry
- Solicitation number
- PE-47200-RFQ-2026-000000127
- Issued by
- Brooks County, Georgia
About this file
This is a Certification Form (Exhibit A) for the Georgia Southern University School of Optometry project (J-460-DP) administered by the Board of Regents of the State of Georgia. The form serves as a sworn statement component of a Request for Qualifications (RFQ) for design professional services related to the School of Optometry facility located in Statesboro, Georgia. Prospective proposers must complete and notarize this certification form as part of their submission, affirming that all information provided in their proposal and Statement of Qualifications is complete, accurate, and truthful.
The certification form requires the proposer's authorized representative to attest that neither the firm nor its principal employees have been convicted of crimes of moral turpitude or felonies, had professional licenses suspended or revoked, or been subjected to disciplinary proceedings within the preceding five years. Additionally, the proposer must certify that it has not been suspended, debarred, or in default on any federal, state, or local government contracts during the same period. The form authorizes the Board of Regents to verify all submitted information through appropriate means, including contact with referenced individuals and entities. False statements or material omissions in the proposal may result in suspension or debarment from future state contracts and potential criminal prosecution under Georgia law and federal statutes.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| _J_460 GSOU_DP RFQ_RFP.pdf | ||
| Exhibit C _ Project Team Composition Form.docx | DOCX document | |
| Exhibit G _ 179D Allocation Agreement.doc | DOC document | |
| Exhibit D _ DP Fee Proposal.doc | DOC document | |
| Egnyte Upload Instructions.pdf | ||
| Exhibit E _ Contractor Affidavit.docx | DOCX document | |
| Exhibit F _ Proposer_s Disclosure Statement.doc | DOC document | |
| Exhibit B _ Certificate of Minority Form.docx | DOCX document |
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Text version
Exhibit A J-460, School of Optometry Georgia Southern University, Statesboro, Georgia
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
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