N_IRELand_form_080404.DOC

Northern Ireland Notice and Certification

State agencies, state authorities, the House of Representatives or the state Senate may not procure goods or services from any person employing ten or more employees in an office or other facility located in Northern Ireland who fails to complete the certification below as required by M.G.L. c.7 section 22C:

_____The bidder does not employ ten or more employees in an office or other facility in Northern Ireland.

_____The bidder employs ten or more employees in an office or other facility located in Northern Ireland and certifies that:

the bidder does not discriminate in employment, compensation, or the terms, conditions and privileges of employment on account of religious or political belief; and the bidder promotes religious tolerance within the work place, and the eradication of any manifestations of religious and other illegal discrimination; and the bidder is not engaged in the manufacture, distribution or sale of firearms, munitions, including rubber or plastic bullets, tear gas, armored vehicles or military aircraft for use or deployment in any activity in Northern Ireland.

Signed under the pains and penalties of perjury on this _____ day of ___________, ____.

Bidder Name

X__________________________________________

Signature of Authorized Representative Signing on Behalf of Bidder

Print Name of Authorized Representative of Bidder

Print Title of Authorized Representative of Bidder

Updated 11/5/98