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West WildwoodYellow Risk

ClosedProfessional Services

download Bid Information 2026 Borough Engineer

BID #: N/A

DUE: 12/23/2025

VALUE: TBD

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Executive Summary

The Borough of West Wildwood is seeking qualifications and proposals from individuals or firms for the position of Borough Engineer. The contract is for either a one-year or a three-year appointment. Submissions must be received by the Borough Clerk, either by mail or in person, no later than December 23, 2025, at 10:00 a.m. prevailing time. Proposals should be enclosed in a sealed envelope plainly marked “Qualifications and Proposal for Borough Engineer Contract” along with the contractor's name and address. A proposed contract must be submitted with the proposal.

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Document Text

--- Document: download Bid Information 2026 Borough Engineer Document ---
GENERAL INFORMATION AND SPECIFICATIONS FOR PROSPECTIVE 
CONTRACTORS SUBMITTING QUALIFICATIONS AND PROPOSALS FOR 
CONTRACT FOR POSITION OF BOROUGH ENGINEER 
I.
Invitation to Submit Qualifications and Proposal. The Borough of West 
Wildwood is requesting qualifications and proposals from individuals and/or 
firms for the following contract for either a one-year appointment or a three-year 
appointment for Borough Engineer, pursuant to N.J.S.A. 40A:9-140. The 
qualifications and proposals are being solicited through a fair and open process in 
accordance with N.J.S.A. 19:44A-20.5, et. seq.  
II.
Submitting and Delivery of Qualifications and Proposals.  Qualifications and 
proposals must be submitted on or before December 23, 2025, and may be 
submitted either by mail or in person by the prospective contractor or his agent.  
Qualifications and proposals must be enclosed in a sealed envelope and plainly 
marked “Qualifications and Proposal for Borough Engineer Contract” and the 
envelope also shall have plainly marked on it the name and address of the 
prospective contractor. 
III.
Time and Place for Acceptance of Qualifications and Proposals.  The West 
Wildwood Borough Clerk has been designated as the person authorized to receive 
all qualifications and proposals.  All qualifications and proposals must be 
submitted in sealed envelopes to the Borough Clerk, Borough of West Wildwood, 
701 W. Glenwood Avenue, West Wildwood, New Jersey, 08260, either by mail or 
in person by the prospective contractor or his agent on or prior to December 23, 
2025 at 10:00 a.m., prevailing time.  The Borough Clerk will record the date and 
time of receipt of all proposals on the sealed envelope.  No proposal will be 
received after the time designated for receipt. 
IV.
Contract Description; Qualifications; Proposal.    
a.
Contract Description.  The Borough Engineer shall perform all of the services 
customarily performed by a Borough Engineer of a Borough the size of the 
Borough of West Wildwood (taking into account its permanent and seasonal 
population).  Such services include, but are not necessarily limited to, the 
following: 
i.
Prepare feasibility studies as requested by the Borough; 
ii.
Perform all necessary field work and prepare drawings and surveys for 
Borough capital improvement projects;  
iii.
Prepare plans in sufficient detail to illustrate the work to be performed for 
subject projects; 
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General Information and Specifications (continued) 
iv.
Prepare plans and specifications in a form as required for public bidding 
and in such detail as is required to describe the work to be performed by 
the contractor for such projects as designated by the Borough. 
v.
Assist the Borough or its representatives in the preparation of the 
necessary applications and/or permit forms as required by the nature of the 
work for submission to the proper agencies of government having 
jurisdiction over the work.  The Borough Engineer shall not be responsible 
for any failure to issue, delay, or conditions imposed by such 
governmental agency. 
vi.
Assist the Borough in the receiving, analyzing and tabulation of bids 
received with recommendations by the Engineer to the Borough or its 
authorized representative. 
vii. Compile sets of contracts for Borough projects; obtain performance bond 
and contract signatures from contractor; forward contracts to Borough for 
approval and following approval by Borough forward contracts to 
contractor along with proceed order. 
viii. Furnish observation of work as to progress and general quality; however, 
Borough Engineer is not responsible for supervising the Borough’s 
contractors or commenting on, overseeing, or providing the means and 
methods of their work, including job site safety and Borough Engineer is 
not responsible for the failure of Borough’s contractors to properly 
perform their work. 
ix.
Review and approve or disapprove shop drawings prepared by contractors 
or manufacturer, but only for the limited purpose of checking for the 
design concept expressed in the drawings and specifications.  Such review 
by Borough Engineer is not conducted for the purpose of determining the 
accuracy and completeness of other details, such as dimensions and 
quantities.  The Borough Engineer’s review shall not constitute approval 
of safety precautions or of construction means, methods, techniques, 
sequences or procedures. 
x.
Report on contractor’s request for change orders and proposals to 
Borough, submit Borough Engineer’s recommendation as to whether or 
not Borough should approve said change order, and prepare change orders 
as approved. 
xi.
Prepare and submit monthly certificates for interim payments according to 
	
contract items as work progresses and prepare and submit a final 
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General Information and Specifications (continued) 
certificate upon completion, said certificate to state that to the best of 
Borough Engineer’s knowledge, based upon the observations made, the 
Contractor has performed in accordance with the plans, specifications and 
change orders. 
xii. Furnish full time resident inspection of the work, if authorized by the 
Borough consisting of: (1) reporting on and making recommendations 
relating to the progress of the work and noting to Borough any observed 
defects, deficiencies and unnecessary delays in the work of the contractor 
(without in any way guaranteeing such work); and (2) approving of 
materials and equipment furnished. 
xiii. Furnish copies of plans and specifications as follows: 
	
 
(a)
One set for Borough during bidding; 
(b)
Three sets to City for preparing contracts; 
(c)
Two sets to State and/or Federal Agencies for approvals 
All other copies as required by Borough or contractors shall be furnished 
at cost of reproduction to those requesting additional copies. 
xiv. Attend Borough meetings when contractor’s proposals are to be accepted. 
xv.
Perform other planning services for the benefit of the Borough upon 
authorization, such as the following:  hydrographic surveys; property 
surveys; easement surveys and descriptions; assisting the Borough in 
connection with adjudication, litigation or negotiation; preparation of 
forms required by various agencies of government for permits or for 
grants or loans; preparation of “as built” drawings upon completion of a 
project from data furnished by contractor; preparation of maps; review of 
site plans and subdivision plans; attending meetings as requested by 
Borough; making drawings from field measurements of existing 
construction when required for planning additions, or alterations thereto; 
additional services due to significant changes in general scope of the 
project or its design, including but not limited to, changes to size, 
complexity or character of construction; revising previously approved 
studies, reports, design documents, and drawings or specifications during 
or after design phase; preparing documents for alternate bids requested by 
the Borough for work which is not executed; preparing detailed 
renderings; exhibits, or scale models for the project; investigations 
involving study of operation, maintenance and overhead expenses, and the 
preparation of rate schedules, earning and expense statements, feasibility 
studies, appraisals and evaluations; additional or extended services during 
construction made necessary by work damaged by fire or other cause 
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General Information and Specifications (continued) 
during construction, prolongation of the construction contract time by 
more than 25%, acceleration of the work schedule involving services and 
normal working hours, and contract default due to Contractor delinquency 
or insolvency; assistance or instruction in the start-up and continued 
operation of equipment or devices and the preparation of manuals of 
operation and maintenance. 
xvi. Maintenance of all Borough maps. 
b. Qualifications. The contractor shall possess all required State of New Jersey 
licenses or certifications. 
The Borough Engineer shall be a duly licensed professional engineer by the State 
of New Jersey in accordance with the provisions of N.J.S.A. 45:14A-1, et. seq., 
and any administrative regulations promulgated thereunder. 
The resume’s or curricula vitae of all individuals who will perform services under 
the contract on behalf of the Borough of West Wildwood shall be submitted with 
the prospective contractor’s proposal. 
c.
Proposal. The prospective contractor’s proposal shall clearly set forth the 
proposed financial compensation to be paid to the contractor under the contract. 
A PROPOSED CONTRACT SHALL BE SUBMITTED WITH THE 
CONTRACTOR’S PROPOSAL.  THE BOROUGH RESERVES THE 
RIGHT TO AUTOMATICALLY REJECT ANY PROPOSAL THAT FAILS 
TO COMPLY WITH THIS REQUIREMENT.   
	
 
V.
Selection Process & Award of Contract.  Upon receipt of qualifications and 
proposals, the Borough Clerk will transmit copies of each proposal to a review 
committee that consists of the Borough Administrator, one Commissioner and 
Borough Solicitor.  Proposals will be evaluated on the basis of the most 
advantageous, price and other factors considered.  The evaluation will consider: 
	
a.	
Experience and reputation of the prospective contractor in the field  
	
	
that is the subject matter of the contract; 
b.	
Knowledge of the Borough of West Wildwood, issues that are  
unique to West Wildwood and the subject matter to be addressed 
under the contract; 
c.	
Availability to accommodate any required meetings of the Borough 
of West Wildwood or its various departments; 
	
d.	
Compensation proposal; and 
	
e.	
Other factors as demonstrated to be in the best interest of the 
	
	
Borough of West Wildwood. 
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General Information and Specifications (continued) 
Upon completion of the review process, the review committee shall transmit its 
findings and recommendations to the Board of Commissioners which may award 
the subject contract on or about January 2, 2026 by resolution. 
VI.
Obligation of Prospective Contractor.  At the time of receipt of proposals, each 
prospective contractor will be presumed to have read and to be thoroughly 
familiar with the contents of the Notice of Availability of Requests for 
Qualifications and Proposals that has been posted on the Borough of West 
Wildwood website and with the contents of this document.  The failure or 
omission of any prospective contractor to receive or examine either document 
shall in no way relieve any prospective contractor from any obligation with 
respect to the proposal submitted. 
VII.
Investigation of Qualifications.  The Borough of West Wildwood will make such 
investigations as it deems necessary to determine the responsibility of the 
prospective contractor and the prospective contractor shall furnish the Borough of 
West Wildwood all such information as may be requested by the Borough of West 
Wildwood notwithstanding the fact that the release of such information to the 
Borough of West Wildwood may result in the disqualification of the prospective 
contractor and the proposal submitted. 
	
The Borough of West Wildwood reserves the right to reject any proposal if the  
evidence submitted by, or the investigation of, such prospective contractor fails to 
satisfy the Borough of West Wildwood that such prospective contractor properly   
is qualified to carry out the obligations of the contract for the work as provided 
and as described in this document. 
VIII.
Signing of Proposal Documentation.  The qualification and proposal 
documentation that is submitted by the prospective contractor shall be signed by 
the individual or on behalf of the entity to be bound by the contract.  
IX.New Jersey Business Registration Certificate; Ownership Disclosure 
Statement; Disclosure of Investment Activities in Iran. Certification of 
Non-Involvement in Prohibited Activities in Russia or Belarus. 
a. New Jersey Business Registration Certificate. Business organizations or 
individuals doing business in New Jersey are required to register with the 
Department of Treasury, Division of Revenue.  Under the provisions of N.J.S.A. 
52:32-44b(1), contractors shall provide the Borough of West Wildwood a copy of 
their New Jersey Business Registration Certification prior to award of a contract 
by Borough of West Wildwood.  Therefore, it is strongly recommended that 
prospective contractors include with their proposal a copy of their New Jersey 
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General Information and Specifications (continued) 
Business Registration Certificate at the time that their proposal is submitted to the 
Borough.    
b. Ownership Disclosure Statement. Prospective contractors are required to 
comply with the requirements of the Public Law, 1975, C.127 N.J.S.A. 34:11-56, 
25 et. seq. as amended in Chapter 64 of the Laws of 1974 and P.L. 1977 Ch. 33, 
N.J.S.A. 52:25-24.2 which requires a statement setting forth the names and 
addresses of all stockholders in the corporation, partnership or limited liability 
company who own 10% or more of its stock, of any class, or of all individual 
partners in the partnership or members of the limited liability company who own 
10% or greater interest therein, as the case may be. An Ownership Disclosure 
Statement is annexed. 
c.  Disclosure of Investment Activities in Iran.  Prospective contractors are 
required to comply with the requirements of P.L. 2012, c.25 and N.J.S.A. 
40A:11-2.1 which require that any person or entity that submits a bid or proposal 
or otherwise proposes to enter into or renew a contract with a local contracting 
unit must complete a certification attesting, under penalty of perjury, that the 
person or entity, or one of the person or entity’s parents, subsidiaries or affiliates 
is not identified on a list created or maintained by the New Jersey Department of 
the Treasury as a person or entity engaging in investment activities in Iran.  A 
Certification is annexed. 
d. Certification of Non-Involvement in Prohibited Activities in Russia or 
Belarus. Pursuant to N.J.S.A. 52:32-60.1, et seq. (L. 2022, c. 3) any 
person or entity (hereinafter “Vendor”) that seeks to enter into or renew a 
contract with a State agency for the provision of goods or services, or the 
purchase of bonds or other obligations, must complete the certification 
below indicating whether or not the Vendor is identified on the Office of 
Foreign Assets Control (OFAC) Specially Designated Nationals and 
Blocked Persons list, available here: https://
sanctionssearch.ofac.treas.gov/.  If the Department of the Treasury finds 
that a Vendor has made a certification in violation of the law, it shall take 
any action as may be appropriate and provided by law, rule or contract, 
including but not limited to, imposing sanctions, seeking compliance, 
recovering damages, declaring the party in default and seeking debarment 
or suspension of the party.   Certification is annexed. 
X.
Miscellaneous.   
a.	
Nothing herein shall be construed as an obligation on the part of the  
Borough of West Wildwood to award the subject contract under the fair 
and open procedures described above and the City of North Wildwood, 
after review of qualifications and proposals that have been submitted, if 
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General Information and Specifications (continued) 
deemed to be in the best interests of the Borough of West Wildwood, 
specifically reserves the right to award the subject contract by utilizing the 
non-fair and open procedures that are set forth at N.J.S.A. 19:44A-20.5, et. 
seq. 
b.	
All contracts awarded by the Borough of West Wildwood shall be 
governed by and interpreted in accordance with the Laws of the State of 
New Jersey. 
	
c.	
For additional information contact:   
	
	
Donna L. Frederick,  Administrator 
	
	
Borough of West Wildwood 
	
	
701 W. Glenwood Avenue 
	
	
West Wildwood, New Jersey, 08260 
	
	
Telephone: 609-522-4845 
	
	
Email: dfrederick@westwildwood.org 
	
XI.	
Proposal Documents Checklist.  Prospective Contractors are required to submit 	
all of the following documents: 
_____	 Proposal in the form described above. 
_____	 Ownership Disclosure Statement 
_____   Disclosure of Investment Activities in Iran 
Certification of Non-Involvement in Russia and Belarus 
_____   New Jersey Business Registration Certificate (Prior to award of contract) 
_____   Resume’s or curricula vitae of all individuals who will perform services 	  
	
 under the contract 
_____   Proposed contract 
Where a form is provided by the Borough of West Wildwood with these 
Specifications, prospective contractors are required to utilize the form 
supplied and substitutions will not be accepted.  If more space is needed to 
complete any form that is supplied than has been provided in the form then 
extra pages are to be attached to the form for which extra space is needed. 
	
Pursuant to the provisions of N.J.S.A. 52:32-44b(1), contractors shall 
provide to the Borough of West Wildwood a copy of their New Jersey 
Business Registration Certificate to the City prior to award of a contract. 
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1
STATEMENT OF OWNERSHIP DISCLOSURE 
N.J.S.A. 52:25-24.2 (P.L. 1977, c.33, as amended by P.L. 2016, c.43) 
This statement shall be completed, certified to, and included with all bid and proposal submissions. Failure to submit the 
required information is cause for automatic rejection of the bid or proposal. 
Name of Organization: 
Organization Address: 
Part  I Check the box that represents the type of business organization: 
Sole Proprietorship (skip Parts II and III, execute certification in Part IV) 
Non-Profit Corporation (skip Parts II and III, execute certification in Part IV) 
For-Profit Corporation (any type)   Limited Liability Company (LLC) 
PartnershipLimited Partnership 	
Limited Liability Partnership (LLP) 
Other (be specific):  	
 
Part II 
 The list below contains the names and addresses of all stockholders in the corporation who own 10 
percent or more of its stock, of any class, or of all individual partners in the partnership who own a 10 
percent or greater interest therein, or of all members in the limited liability company who own a 10 
percent or greater interest therein, as the case may be. (COMPLETE THE LIST BELOW IN THIS 
SECTION) 
OR 
 No one stockholder in the corporation owns 10 percent or more of its stock, of any class, or no 
individual partner in the partnership owns a 10 percent or greater interest therein, or no member in the 
limited liability company owns a 10 percent or greater interest therein, as the case may be.  (SKIP TO 
PART IV) 
(Please attach additional sheets if more space is needed): 
Name of Individual or Business Entity
Home Address (for Individuals) or Business Address


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2
 
Part III DISCLOSURE OF 10% OR GREATER OWNERSHIP IN THE STOCKHOLDERS, PARTNERS OR LLC 
MEMBERS LISTED IN PART II 
If a bidder has a direct or indirect parent entity which is publicly traded, and any person holds a 10 percent or greater 
beneficial interest in the publicly traded parent entity as of the last annual federal Security and Exchange Commission 
(SEC) or foreign equivalent filing, ownership disclosure can be met by providing links to the website(s) containing the last 
annual filing(s) with the federal Securities and Exchange Commission (or foreign equivalent) that contain the name and address of 
each person holding a 10% or greater beneficial interest in the publicly traded parent entity, along with the relevant page numbers 
of the filing(s) that contain the information on 
each such person.  Attach additional sheets if more space is needed. 
Please list the names and addresses of each stockholder, partner or member owning a 10 percent or greater interest in any 
corresponding corporation, partnership and/or limited liability company (LLC) listed in Part II other than for 
any publicly traded parent entities referenced above.  The disclosure shall be continued until names and addresses of every 
noncorporate stockholder, and individual partner, and member exceeding the 10 percent ownership criteria established pursuant to 
N.J.S.A. 52:25-24.2 has been listed. Attach additional sheets if more space is needed. 
Part IV 	 Certification 
I, being duly sworn upon my oath, hereby represent that the foregoing information and any attachments thereto to the best of my 
knowledge are true and complete. I acknowledge: that I am authorized to execute this certification on behalf of the bidder/proposer; that 
The Borough of West Wildwood is relying on the information contained herein and that I am under a continuing obligation from the date of 
this certification through the completion of any contracts with the Borough of West Wildwood to notify the Borough of West Wildwood in 
writing of any changes to the information contained herein; that I am aware that it is a criminal offense to make a false statement or 
misrepresentation in this certification, and if I do so, I am subject to criminal prosecution under the law and that it will constitute a material 
breach of my agreement(s) with the, permitting the Borough of West Wildwood to declare any contract(s) resulting from this certification 
void and unenforceable. 
Website (URL) containing the last annual SEC (or foreign equivalent) filing
Page #’s
Stockholder/Partner/Member and 
Corresponding Entity Listed in Part II
Home Address (for Individuals) or Business Address


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3
Full Name (Print):
Title:
Signature:
Date:


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4
The Certification form requires the insertion of contracting unit identification information which 
should be filled in (in italics on the form) prior to its use. 
STANDARD BID DOCUMENT REFERENCE
Name of Form DISCLOSURE OF INVESTMENT ACTIVITIES IN IRAN
Statutory 
Reference
N.J.S.A. 52:32-55 et seq. 
N.J.S.A. 40A:11-2.1 
N.J.S.A. 18A:18A-49.4
Applicability
Y/N
Mandatory
Optional
N/A
LPCL
Y
Goods and 
Services
X
PSCL
Y
Construction
X
Instructions 
Reference
Description
P.L. 2012, c.25 prohibits the awarding of State and local public contracts for g
services with persons or entities engaging in certain investment activities in en
finance sectors of Iran. Prior to contract award, vendors and contractors must 
neither they nor any parent entity, subsidiary, or affiliate is listed on the New J
Department of the Treasury’s list of entities determined to be engaged in proh
activities in Iran pursuant to P.L. 2012, c. 25 ("Chapter 25 List"). 
Disclosure of Investment Activities in Iran
Person or Entity
Part 1: Certification


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5
COMPLETE PART 1 BY CHECKING EITHER BOX. 
 Pursuant to Public Law 2012, c. 25, any person or entity that is a successful bidder or p
otherwise proposes to enter into or renew a contract, must complete the certification below to a
penalty of perjury, that neither the person or entity, nor any parent entity, subsidiary, or affiliate i
on the State Department of Treasury's Chapter 25 list as a person or entity engaging in investme
in Iran. The list is found on Treasury’s website at www.state.nj.us/treasury/purchase/pdf/Chapter
The Chapter 25 list must be reviewed prior to completing the below certification.  If a vendor o
is found to be in violation of law, action may be taken as appropriate and as may provided by 
contract, including but not limited to imposing sanctions, seeking compliance, recovering
declaring the party in default and seeking debarment or suspension of the party.

 I certify, pursuant to Public Law 2012, c. 25, that neither the person o
listed above, nor any parent entity, subsidiary, or affiliate thereof is listed
N.J. Department of the Treasury’s list of entities determined to be eng
prohibited activities in Iran pursuant to P.L. 2012, c. 25 ("Chapter 25 L
further certify that I am the person listed above, or I am an off
representative of the entity listed above and am authorized to ma
certification on its behalf. I will skip Part 2 and sign and compl
Certification below.
OR

I am unable to certify as above because the person or entity and/or a paren
subsidiary, or affiliate thereof is listed on the N.J. Department of the Tre
Chapter 25 list. I will provide a detailed, accurate and precise descriptio
activities in Part 2 below sign and complete the Certification below. 
Part 2: Additional Information


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6
CERTIFICATION OF NON‐INVOLVEMENT IN PROHIBITED ACTIVITIES IN 
RUSSIA OR BELARUS 
Pursuant to N.J.S.A. 52:32-60.1, et seq. (P.L. 2022, c. 3) any person or entity (hereinafter “Vendor
i”) that seeks 
to enter into or renew a contract with a State agency for the provision of goods or services, or the purchase of 
bonds or other obligations, must complete the certification below indicating whether or not the Vendor is 
engaged in prohibited activities in Russia or Belarus
ii. If the Department of the Treasury finds that a Vendor has 
made a certification in violation of the law, it shall take any action as may be appropriate and provided by law, 
rule or contract, including but not limited to, imposing sanctions, seeking compliance, recovering damages, 
declaring the party in default and seeking debarment or suspension of the party. 
PLEASE PROVIDE FURTHER INFORMATION RELATED TO INVESTMENT ACTIVITIES
You must provide a detailed, accurate and precise description of the activities of the person or 
parent entity, subsidiary, or affiliate thereof engaging in investment activates in Iran below a
space is needed, on additional sheets provided by you.
Part 3: Certification of True and Complete Information
       I, being duly sworn upon my oath, hereby represent and state that the foregoing inform
any attachments there to the best of my knowledge are true and complete. I attest that I am a
to execute this certification on behalf of the above-referenced person or entity. 
      I acknowledge that the Name of Contracting Unit is relying on the information contain
and thereby acknowledge that I am under a continuing obligation from the date of this ce
through the completion of any contracts with the Reference to Contracting Unit to notify the R
to Contracting Unit in writing of any changes to the answers of information contained herein. 
      I acknowledge that I am aware that it is a criminal offense to make a false sta
misrepresentation in this certification, and if I do so, I recognize that I am subject to
prosecution under the law and that it will also constitute a material breach of my agreement(s
Name of Contracting Unit and that the Reference to Contracting Unit at its option may de
contract(s) resulting from this certification void and unenforceable.
Full Name (Print
Title
Signature
Date


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7
CERTIFICATION 
I, the undersigned, certify that I have read the definition of “Vendor” below, and have reviewed the Department 
of the Treasury’s list of Vendors engaged in prohibited activities in Russia or Belarus, and having done so 
certify: 
 
Definitions 
i Vendor means: (1) A natural person, corporation, company, limited partnership, limited liability partnership, 
limited liability company, business association, sole proprietorship, joint venture, partnership, society, trust, or 
any other nongovernmental entity, organization, or group; (2) Any governmental entity or instrumentality of a 
government, including a multilateral development institution, as defined in Section 1701(c)(3) of the 
International Financial Institutions Act, 22 U.S.C. 262r(c)(3); or (3) Any parent, successor, subunit, direct or 
indirect subsidiary, or any entity under common ownership or control with, any entity described in paragraph (1) 
or (2). 
ii Engaged in prohibited activities in Russia or Belarus means: (1) companies in which the Government of 
Russia or Belarus has any direct equity share; (2) having any business operations commencing after the 
effective date of this act that involve contracts with or the provision of goods or services to the Government of 
Russia or Belarus; (3) being headquartered in Russia or having its principal place of business in Russia or 
Belarus, or (4) supporting, assisting or facilitating the Government of Russia or Belarus in their campaigns to 
invade the sovereign country of Ukraine, either through in-kind support or for profit.
(Check the Appropriate Box)
That the Vendor is not identified on the Department of the Treasury’s list of Vendors engaged in prohibited activit
Russia or Belarus.
OR
That I am unable to certify as to “A” above, because the Vendor is identified on the Department of the Treasury’s 
Vendors engaged in prohibited activities in Russia and/or Belarus.
OR
That I am unable to certify as to “A” above, because the Vendor, though not identified on the Department of the Treasu
of Vendors engaged in prohibited activities in Russia or Belarus, is engaged in prohibited activities in Russia or Be
detailed, accurate and precise description of the Vendor’s activity in Russia and/or Belarus is set forth below.
Description of Prohibited Activity (Attach Additional Sheets If Necessary.)
    
    
     
C.
Signature of Vendor’s Authorized Representative
Date
Print Name and Title of Vendor’s Authorized Representative
Vendor’s FEIN
Vendor’s Name
Vendor’s Phone Number
Vendor’s Address (Street Address)
Vendor’s Fax Number
Vendor’s Address (City/State/Zip Code)
Vendor’s Email Address

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