Attachment_12.docx

Attachment 12

CONTRACTOR CERTIFICATE AND GOVERNMENT GRANT OF COMMISSION

I. CONTRACTOR CERTIFICATE

I certify, according to the provisions of ____________ (cite the state rule) of the State Rules of Civil Procedure, that the individual(s) whose name(s) and title(s) is(are) listed below:

(list the names and titles of the individuals the Contractor agency head is recommending for FDA commission. If a separate page is used to list the names and title, incorporate that page by reference)

(1) meets the requirements the Contractor has established to credential its own officer to carry out State government regulatory or enforcement responsibilities,

(2) has provided the Contractor with a written assurance that the individual understands the importance of maintaining confidentiality of non-public information created or obtained under this contract, and will comply with the provisions of section H (“Special Contract Requirements”) regarding confidentiality,

(3) has provided the Contractor with a written assurance that the individual will not use information created or obtained under this contract to further the individual’s private interests or the interests of any other person,

(4) has provided the Contractor with a written assurance that the individual has no personal financial interest or any other financial or business relationship with any person operating in the specific program area(s) in which the Contractor would grant authority to the official as a credentialed officer, and

(5) meets the requirements of the Government’s commissioning procedures.

In witness whereof, I have, pursuant to the provisions of _________________ (cite the State rule), set my hand and caused the seal of the _______________________ (name of the Contractor State agency) to be affixed this _______ day of _____________, 201_.

Name of Contractor agency head: _______________________________

Title of Contractor agency head: _______________________________

Name of State and agency: _______________________________

II. GOVERNMENT GRANT OF COMMISSION

Based on the signed certification (above) provided by the Contractor agency head, the Government grants a commission(s) pursuant to Government commissioning procedures to the individual(s) whose name(s) is/are listed above. All other provisions of the Government’s commissioning provisions remain in effect.

Food and Drug Administration