Proposal Certification Form.doc

REQUEST FOR PROPOSAL CERTIFICATION FORM

Building C Meeting Room Carpet Replacement Phase IV

RFP #: GWCCA071326MM

I further certify that to the best of my knowledge the information given in response to the Request for Proposal is full, complete and truthful.

I further certify that the submitting firm and any principal employee of the submitting firm has not, in the immediately preceding five (5) 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 submitting firm has not, in the immediately preceding five (5) years, been suspended or debarred from contracting with any federal, state or local government agency, and further, that the submitting firm is not now under consideration for suspension or debarment from any such agency.

I further certify that the submitting firm has not in the immediately preceding five (5) years been defaulted in any federal, state or local government agency contract and further, that the submitting firm 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 Authority may, by means that either deems appropriate, determine the accuracy and truth of the information provided by the proposer and that the Authority may contact any individual or entity named in the Proposal for the purpose of verifying the information supplied therein.

I acknowledge and agree that all of the information contained in the Proposal is submitted for the express purpose of inducing the Authority to award a contract.

I certify we have not employed or retained any company or person, other than a bona fide employee working solely for it, to solicit or secure this contract and that we have not paid or agreed to pay any person, company, corporation, individual, or firm, other than a bona fide employee working solely for us, any fee, commission, percentage, gift, or other consideration contingent upon or resulting from the award or the making of this contract.

I certify that any proposal we submit for this project shall be made without prior understanding, agreement, or connection with any corporation, firm, or person submitting or who will be submitting a separate proposal on the same project or for the same services, materials, labor, supplies, or equipment and is in all respects fair and without collusion or fraud. We understand collusive bidding is a violation of state and federal law and can result in fines, prison sentences, and civil damage awards. We agree to abide by all conditions of this solicitation. We certify that no person associated with our firm is a member of the Board of Governor’s or officer or employee of the Authority or holds any statewide elective or appointed office. We further certify that no person who holds any state-wide elective or appointed office or who is a member of the Board of Governors or officer or employee of the Authority has been paid or promised by the firm any compensation in connection with this procurement by the Authority.

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.

Sworn and subscribed before me

This day of , 20 . Signature

NOTARY PUBLIC

My Commission Expires: NOTARY SEAL