W911KF19Q0081_CMM.pdf

(No Collect Calls)

(TYPE OR PRINT)

(TYPE OR PRINT)

31b. NAME OF CONTRACTING OFFICER

31a.UNITED STATES OF AMERICA

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, AND 30

EMAIL:

TEL:

31c. DATE SIGNED

(Print)

(Location)

(YY/MM/DD)

Buy American Act-Free Trade Agreements-Israeli Trade Act Certificate, Alternate I (Jan 2004)

Certification Regarding Responsibility Matters (Executive Order 12689)

The tax liability is finally determined.

The taxpayer is delinquent in making payment.

Listed End Products (Executive Order 13126) The Contracting Officer must list in paragraph (i)(1) any end products being acquired under this solicitation that are included in the List of Products Requiring Contractor Certification as to Forced or Indentured Child Labor, unless excluded at (b)

Listed end products

Certification If the Contracting Officer has identified end products and countries of origin in paragraph (i)(1) of this provision, then the offeror must certify to either (i)(2)(i) or (i)(2)(ii) by checking the appropriate block

Place of manufacture.

The contracting officer is to check a box to indicate if paragraph (k)(1) or (k)(2) applies.

Representation and Certifications e.g.

Ownership or Control of Offeror

Representation by Corporations Regarding Delinquent Tax Liability or a Felony Conviction under any Federal Law.

Additional license rights

Release from liability

Field Name in WAWF Data to be entered in WAWF

Form Approved OMB No. 0704-0188

Page ___ of _____ Pages Designed using Perform Pro, WHS/DIOR, Aug 96

PREVIOUS EDITION MAY BE USED.DD FORM 1664, AUG 96 (EG)

DATA ITEM DESCRIPTION

1. TITLE 2. IDENTIFICATION NUMBER

3. DESCRIPTION/PURPOSE

4. APPROVAL DATE

(YYYYMMDD)

5. OFFICE OF PRIMARY RESPONSIBILITY (OPR) 6a. DTIC APPLICABLE 6b. GIDEP APPLICABLE

7. APPLICATION/INTERRELATIONSHIP

8. APPROVAL LIMITATION 9a. APPLICABLE FORMS 9b. AMSC NUMBER

10. PREPARATION INSTRUCTIONS

11. DISTRIBUTION STATEMENT

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (0704-0188), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS.

Coordinate Measuring Machine (CMM) Printed and CD-ROM Manuals for operations, parts and service.

(2) Sets of CD-ROM and (2) Sets of printed Operator's Manual, Parts Manual, and Service Manual

EVIDENCE OF AUTHORITY TO SIGN OFFERS

Reference the solicitation provision in Section I entitled “Signature Authority.” Evidence of the authority of individuals signing offers to submit firm offers on behalf of the Offeror is required except for the owner in the case of sole proprietorships. When Contractor is a corporation, complete this certificate.

CERTIFICATE OF CORPORATE OFFICIAL/AGENT’S AUTHORITY TO BIND CORPORATION

I, _________________________________, Secretary of ________________________________________

_________________________________, a corporation created and organized under the law of the State of

__________________________, do hereby certify that ___________________________ is an official/agent of said corporation and is empowered to represent, bind and execute contracts on behalf of said corporation, subject to the following limitations:__________________________________________________________.

(if none, so state)

Witness my hand and the corporate seal of said corporation this ______ day of ______________, 20____.

(CORPORATE SEAL) ________________________________________

Secretary

When Contractor is a Partnership, Unincorporated Firm or a Corporation for which completion of the first statement would be impracticable, complete this certificate:

CERTIFICATE OF AUTHORITY TO BIND PARTNERSHIP

We, the undersigned, comprising the total membership of _____________________________________________

_________________________________________________, a partnership/unincorporated firm doing business at_______________________________________________________________________, do hereby certify that ____________________________________ is a ____________________________ of said firm and is empowered to represent, bind, and execute contracts on behalf of said partnership/ unincorporated firm.

Witness our signatures, this _______ day of ________________, 20____.

Members of Partnership/Unincorporated Firm: