Exhibit A _ Certification Form.docx
DOCX document 35 KB Posted
- Attached to
- CLSU J-475-DB Campus Infrastructure Phase III
- Solicitation number
- PE-47200-RFQ-2027-000000153
- Issued by
- Clayton County, Georgia
About this file
This is a Certification Form for Project No. J-475, Campus Infrastructure Phase III at Clayton State University in Morrow, Georgia, submitted to the Board of Regents. The form requires the proposer's authorized representative to certify that they have read and understand the attached proposal and all enclosures and exhibits, and that all information provided in response to the request for proposals is complete and truthful. The certifying individual must affirm that neither the proposer nor any principal employee has 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.
The certification further requires the proposer to attest that it has not been suspended or debarred from contracting with any federal, state, or local government agency during the preceding five years, is not under consideration for such suspension or debarment, and has not defaulted on any government contract or received notice of intent to default. The form authorizes the Board of Regents to verify the accuracy of all submitted information by contacting individuals or entities named in the Statement of Qualifications. The document warns that material false statements or omissions may result in suspension or debarment from future state contracts, contract rescission, and criminal prosecution under Georgia law and federal statutes including O.C.G.A. 16-10-20, 18 U.S.C. § 1001, and 18 U.S.C. § 1341. The certification must be notarized and signed by an authorized representative of the proposing firm.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Exhibit C _ DB Fee Proposal.docx | DOCX document | |
| Exhibit D _ Precon Cost and Expenses.xlsx | XLSX spreadsheet | |
| _CLSU J_475 DB RFQ_RFP.pdf | ||
| Exhibit F _ Project Cost Matrix.xlsx | XLSX spreadsheet | |
| Exhibit E _ General Conditions Breakdown.xlsx | XLSX spreadsheet | |
| Exhibit G _ Proposer_s Disclosure Statement.doc | DOC document | |
| Exhibit B _ Contractor Affidavit.docx | DOCX document | |
| Egnyte Upload Instructions.pdf |
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Text version
Exhibit A Project No. J-475, Campus Infrastructure Phase III Clayton State University
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: _________________
Dalton State College J-472 Utilities Upgrades Phase 1 DB RFQ/RFP
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