CERTIFICATION FORM
TO THE STATE OF ARIZONA:
The undersigned hereby offers and agrees to furnish the service in compliance with all terms, conditions,
and specifications and amendments in the Proposal and any written exceptions in the offer. Signature
certifies understanding and compliance with the State of Arizona Uniform Terms and Conditions, as well
as the following:
A. Non-collusion, Employment, and Services. By signing the Offer and Acceptance Form or
other official contract form, the Offeror certifies that:
1. It did not engage in collusion or other anti-competitive practices in connection
with the preparation or submission of its Offer; and
2. It does not discriminate against any employee or applicant for employment or
person to whom it provides services because of race, color, religion, sex, national
origin, or disability, and that it complies with all applicable federal, state and
local laws and executive orders regarding employment.
B. Disclosure. If the firm, business or person submitting this Offer has been debarred,
suspended or otherwise lawfully precluded from participating in any public
procurement activity, including being disapproved as a subcontractor with any federal,
state or local government, or if any such preclusion from participation from any public
procurement activity is currently pending, the Offeror shall fully explain the
circumstances relating to the preclusion or proposed preclusion in the Offer. The Offeror
shall include a letter with its Offer setting forth the name and address of the
governmental unit, the effective date of this suspension or debarment, the duration of the
suspension or debarment, and the relevant circumstances relating the suspension or
debarment. If suspension or debarment is currently pending, a detailed description of all
relevant circumstances including the details enumerated above shall be provided.
C. Disqualification. The Offer of an Offeror who is currently debarred, suspended or
otherwise lawfully prohibited from any public procurement activity shall be rejected.
Firm Name
Address
City State Zip
The Applicant has caused this document to be duly executed as of this day of 2017.
Offeror's Authorized Signature
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signature
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