Attachment 2 - Self-Certification for Antimafia.pdf

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Healthcare Environmental Cleaning and Linen Laundry Services
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W9114F25QA037
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Attachment 2 is an Italian self-certification form for antimafia communication (Autocertificazione della comunicazione antimafia), which is a declaration of certification under D.P.R. n. 445 of 28.12.2000. The document is a template for an individual to declare that they do not have any disqualifying conditions under Article 67 of Legislative Decree No. 159 of 06/09/2011, which relates to anti-mafia regulations.

The form requires the declarant to provide personal details such as name, tax code, birthplace, residence, and their role in a company. By completing the form, the individual acknowledges potential legal penalties for false statements and consents to the processing of personal data under Legislative Decree No. 196/2003. The form includes spaces for the declarant's signature, date, and other identifying information, and is designed to be used in official procedures requiring verification of an individual's status in relation to anti-mafia regulations.

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ATTACHMENT 2

Autocertificazione della comunicazione antimafia.

Dichiarazione sostitutiva di certificazione (D.P.R. n. 445 del 28.12.2000)

Il/la sottoscritto/a (nome e cognome) C.F._ nato/a Prov. il residente a Prov. in via/piazza

n. , in qualità di (carica ricoperta) dell’impresa

(indicare la denominazione)

C.F.

avente la sede in n.

Prov. di Via consapevole delle sanzioni penali in caso di dichiarazioni false e della conseguente decadenza dai benefici eventualmente conseguiti (ai sensi degli artt. 75 e 76 D.P.R. 445/2000) sotto la propria responsabilità

DICHIARA

che nei propri confronti non sussistono le cause di divieto, di decadenza o di sospensione di cui all’art. 67 del D.lgs. n. 159 del 06/09/2011.

Il/la sottoscritto/a dichiara inoltre di essere informato/a, ai sensi del D.Lgs. n. 196/2003 (codice in materia di protezione di dati personali) che i dati personali raccolti saranno trattati, anche con strumenti informatici, esclusivamente nell’ambito del procedimento per il quale la presente dichiarazione viene resa.

data firma leggibile del dichiarante (2)

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