Purchasing Certification Form - City Of Urbana printable pdf download

Purchasing Certification Form - City Of Urbana

CITY OF URBANA, ILLINOIS

PURCHASING CERTIFICATION FORM (Rev. 4/06)

The City of Urbana requires all vendors doing business at the above levels with the

City to comply with certain local, state and federal requirements. By signing below, the

vendor certifies, that they are familiar with and are in compliance with all of the

legislative acts summarized below. False certification on this form, or the failure to fully

comply with all of the requirements of these acts, may result in the termination of any

contract, debarment from future contacts from either the City of Urbana, State of Illinois

or any other governmental agency, and may subject the vendor to other legal actions.

DRUG FREE WORKPLACE ACT: An act to create a drug free workplace and prevent

the unlawful manufacture, distribution, dispensation, possession, or use of a controlled

substance by anyone while involved in the performance of a contract for the City of

Urbana. (30 ILCS 580/1 et. seq.)

CERTIFICATION OF COMPLIANCE: An act to insure that all contracts for goods,

services or construction are obtained only through an independent noncollusive

submission of offers, the vendor must certify that it is not barred from contracting with

any unit of the State of Illinois or any Illinois local governmental agency as a result of

any bid-rigging or bid-rotating. (720 ILCS 5/33E 1 et. seq.)

DELINQUENT TAXPAYERS: An act to certify that any vendors doing business with

the City of Urbana are not delinquent in the payment of any tax administered by the

Illinois Department of Revenue. (65 ILCS 5/11-42.1-1)

SIGNATURES (COMPLETE APPROPRIATE SECTION)

INDIVIDUAL[ ] PARTNERSHIP [ ] CORPORATION [ ] (check one)

Name of the Business _________________________________________________

Signed By: __________________________________________________________

Printed Name: _______________________________________________________

Business Address: _____________________________________________________

Business Phone Number: _______________________________________________

Date ____________________________________________

Purchasing Certification Form - City Of Urbana