Exhibit A _ RFQ Certification Form.docx
DOCX document 33 KB Posted
- Attached to
- GSOU J-460-PM School of Optometry
- Solicitation number
- PE-47200-RFQ-2026-000000126
- Issued by
- Brooks County, Georgia
About this file
This is a certification form for an RFQ related to Program Management Services for Project No. J-460-PM, School of Optometry at Georgia Southern University in Statesboro, Georgia. The certification form serves as a sworn statement that must be completed and notarized by an authorized representative of the proposing firm. The form requires the certifying official to attest that they have read and understand the proposal and all enclosures, that the information provided is full, complete, and truthful, and that they are authorized to bind the firm to the commitments contained in the proposal. The document does not specify response dates, due dates, site visits, bidders' meetings, or award dates, as it functions solely as a certification requirement within the broader RFQ process.
The certification form requires proposers to verify their eligibility and compliance status across multiple dimensions. Proposers must confirm that neither they nor their 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, proposers must certify they have not been suspended or debarred from contracting with any federal, state, or local government agency, nor are they currently under consideration for such suspension or debarment. Proposers must also attest that they have not defaulted on any government contract within the previous five years and are not under notice of intent to default. The certification authorizes the Board of Regents to verify all information submitted and warns that material false statements or omissions constitute grounds for suspension, debarment, contract denial, or contract rescission, and may result in criminal prosecution under Georgia law or federal statutes including O.C.G.A. 16-10-20, 18 U.S.C. § 1001, or 18 U.S.C. § 1341.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Exhibit D _ PM Fee Proposal Form.xlsx | XLSX spreadsheet | |
| Exhibit E _ Contractor Affidavit.docx | DOCX document | |
| Exhibit F _ Proposer_s Disclosure Statement.doc | DOC document | |
| Egnyte Upload Instructions.pdf | ||
| Exhibit B _ Certificate of Minority Form.docx | DOCX document | |
| J_460 GSOU School of Optometry PM RFQ_RFP_djh.pdf | ||
| Exhibit C _ Project Team Composition 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 ________, 202__.
NOTARY PUBLIC
NOTARY SEAL
My Commission Expires: _________________
Gordon State College PPV-89-1201, Student Activity & Rec Ctr., PM RFQ/RFP
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