Form 5 - PUR 2023 and PUR 2024 Combined.pdf
PDF 89 KB Posted
- Attached to
- ITB-DEM-25-26-020 - WebEOC
- Solicitation number
- ITB-15570
- Issued by
- Leon County, Florida
About this file
This is a compliance certification form (Form 5 - PUR 2023 and PUR 2024 Combined) required by the State of Florida for the WebEOC contract opportunity (ITB-DEM-25-26-020) issued by the Florida Division of Emergency Management. The form consists of two separate certification requirements that must be completed by authorized representatives of any nongovernmental entity submitting a response to this solicitation for a web-based emergency management software tool and related services.
The PUR 2024 section requires an officer or representative of the bidding entity to certify under penalties of perjury that the company does not use coercion for labor or services as defined in Florida Statutes section 787.06(14). The PUR 2023 section requires a member of the company's senior management (as defined in section 287.1346, F.S., including chief executive officers, vice presidents, chief financial officers, or equivalent positions) to certify that commodities being offered have not been produced in whole or in part by forced labor, as required by Florida Statutes section 287.1346(4)(b). Both certifications must be signed and dated by the appropriate company representative, with the entity name, representative name, and title clearly documented on the form.
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PUR 2024: Use of Coercion for Labor or Services
Pursuant to section 787.06(14), Florida Statutes, this portion of the form must be completed by an officer or representative of the nongovernmental entity executing, renewing, or extending a contract with a governmental entity.
The entity named below does not use coercion for labor or services as defined in section 787.06, Florida Statutes.
Under penalties of perjury, I declare that I have read the foregoing statement and that the facts stated in it are true.
Entity Name:
Representative/Officer’s Printed Name:
Representative/Officer’s Title:
Signature: Date:
PUR 2023: Provision of Commodities Produced by Forced Labor
Pursuant to section 287.1346(4)(b), Florida Statutes, this portion of the form must be completed by a member of the company’s senior management, as defined in section 287.1346, F.S., when the company submits a response to a solicitation for the provision of commodities and before the company enters into or renews a contract for the provision of commodities.
As defined in section 287.1346(c), Florida Statutes, “Senior management” includes chief executive officers;
assistant chief executive officers, including, but not limited to, assistant presidents, vice presidents, or assistant treasurers; chief financial officers; chief personnel officers; or any employee of an entity performing similar functions.
I certify that to the best of my knowledge, the commodities the entity named below is offering to the Department have not been produced, in whole or in part, by forced labor.
Entity Name:
Senior Management’s Printed Name:
Senior Management Member’s Title:
Signature: Date:
| Date7_af_date: |
| Date8_af_date: |
| Title: |
| Printed Name: |
| Entity Name: |
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