Exhibit A _ Certification Form.docx
DOCX document 34 KB Posted
- Solicitation number
- PE-47200-RFQ-2026-000000147
- Issued by
- Brantley County, Colquitt City, Georgia
About this file
This is a Certification Form for Design Professional Services related to Project No. J-469-DP, the Cochran Campus Domestic Water System Replacement at Middle Georgia State University in Cochran, Georgia, under the oversight of the Board of Regents of the State of Georgia. The form requires the proposer's authorized representative to certify in writing, under oath before a notary public, that they have read and understand all proposal information and that the submitted information is complete and truthful. The certification must be notarized and included with the proposal submission.
The certification form requires the proposer to affirm that neither the firm nor its principal employees have been convicted of crimes of moral turpitude or felonies within the preceding five years, nor have had professional licenses suspended or revoked. Proposers must also certify that they have not been suspended or debarred from contracting with any federal, state, or local government agency within the preceding five years and are not currently under consideration for such action. Additionally, the form requires certification that the proposer has not defaulted on any government contract within five years and is not under notice of intent to default. The form authorizes the Board of Regents to verify all submitted information and warns that material false statements or omissions may result in suspension, debarment, contract denial, or criminal prosecution under Georgia law or federal statutes including O.C.G.A. 16-10-20, 18 U.S.C. § 1001, and 18 U.S.C. § 1341.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Egnyte Upload Instructions.pdf | ||
| Exhibit F _ Proposers Disclosure Statement.doc | DOC document | |
| Exhibit B _ Certificate of Minority Form.docx | DOCX document | |
| Exhibit C _ Project Team Composition Form.docx | DOCX document | |
| _MGSU J_469 DP RFQ_RFP.pdf | ||
| Exhibit G _ 179D Allocation Agreement.doc | DOC document | |
| Exhibit D _ DP Fee Proposal.doc | DOC document | |
| Exhibit E _ Contractor Affidavit.docx | DOCX document |
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Text version
Exhibit A J-469 Cochran Campus Domestic Water System Replacement Middle Georgia State University, Cochran, 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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