Food Service Management Contract Form (Page 3 of 4) in pdf

Food Service Management Contract Form Page 3

Certification regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion

Contracts/Subcontracts

This certification is required by the regulation implementing Executive Order 12549, Debarment and Suspension,

signed February 18, 1986. The guidelines were published in the May 29, 1987, Federal Register (52 Fed. Reg.,

pages 20360-20369).

(1)

The prospective vendor certifies, by signing this certification, that neither he nor his principals are

presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from

participation in contracting with the Department of Elder Affairs by any federal department or agency.

(2)

Where the prospective vendor is unable to certify to any of the statements in this certification,

such prospective vendor shall attach an explanation to this certification.

Vendor Signature ___________________________________________ Date

_____/_____/______

Printed Name and Title of Authorized Individual

_________________________________________

Name of Organization

_________________________________________

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Rev.7/28/15

Food Service Management Contract Form Page 3