UWG J-463-DP, TLC Lecture Hall Renovation and Systems Renewal

Exhibit A

J-463, TLC Lecture Hall Renovation and Systems Renewal

University of West Georgia, Carrollton, Georgia

CERTIFICATION FORM

I, _____________________________, being duly sworn, state that I am ______________________(title) of _______________________________(firm) and hereby duly certify that I have read and understand the information presented in the attached proposal and any enclosure and exhibits thereto.

I further certify that to the best of my knowledge the information given in response to the request for proposals is full, complete and truthful.

I further certify that the proposer and any principal employee of the proposer have not, in the immediately preceding five years, been convicted of any crime of moral turpitude or any felony offense, nor has had their professional license suspended, revoked or been subjected to disciplinary proceedings.

I further certify that the proposer has not, in the immediately preceding five years, been suspended or debarred from contracting with any federal, state or local government agency, and further, that the proposer is not now under consideration for suspension or debarment from any such agency.

I further certify that the proposer has not in the immediately preceding five years been defaulted in any federal, state or local government agency contract, and further, that the proposer is not now under any notice of intent to default on any such contract.

I acknowledge, agree and authorize, and certify that the proposer acknowledges, agrees and authorizes, that the Board of Regents may, by means that the Board of Regents deems appropriate, determine the accuracy and truth of the information provided by the proposer and that the Board of Regents or their agents may contact any individual or entity named in the Statement of Qualifications for the purpose of verifying the information supplied therein.

I acknowledge and agree that all of the information contained in the Statement of Qualifications is submitted for the express purpose of inducing the Owner to award a contract.

A material false statement or omission made in conjunction with this proposal is sufficient cause for suspension or debarment from further contracts, or denial of rescission of any contract entered into based upon this proposal thereby precluding the firm from doing business with, or performing work for, the State of Georgia. In addition, such false statement or omission may subject the person and entity making the proposal to criminal prosecution under the laws of the State of Georgia of the United States, including but not limited to O.C.G.A. 16-10-20, 18 U.S.C. 1001 or 1341.

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Signature

Sworn and subscribed before me

This _____ day of ________, 20__.

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NOTARY PUBLIC

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NOTARY SEAL

My Commission Expires: _________________