B08-Attach 8_Antimafia_.pdf
PDF 389 KB Posted
- Solicitation number
- W912PF-26-Q-A032
About this file
Request for Quotation W912PF26QA032
This document is a self-certification form for antimafia communication compliance required as part of Request for Quotation W912PF26QA032. The form is bilingual, presented in both English and Italian, and serves as a substitutive declaration of certification under Italian law (D.P.R. n. 445 del 28.12.2000 and D.P.R. n. 445 del 28.12.2000).
The form requires completion by an authorized company representative, including personal identification information (name, tax identification number, birthplace, residence) and company details (business name, tax identification number, registered office address). The signatory must declare under penalty of perjury that no circumstances exist that would impose prohibitions, debarment, or suspension under Article 67 of Italian Legislative Decree 159/2011 (antimafia legislation). The declarant must also acknowledge awareness that personal data collected will be processed exclusively for the procurement procedure and may be handled through electronic means in accordance with Italian data protection law (D.Lgs. n. 196/2003). The form requires the declarant's legible signature and date but does not address specific products, services, or contract terms.
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Text version
Request for Quotation W912PF26QA032
Self-certification for Antimafia communication
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 _________________________ Prov. di __________ Via ___________________________ n. ______ 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)
File details come from the government source that posted it. Updated .