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AG 2010 10 18
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AG 2010 10 18
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Last modified
11/15/2011 8:59:39 AM
Creation date
11/27/2017 11:23:37 AM
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Template:
Meeting Minutes
Doc Type
Agenda
Meeting Minutes - Date
10/14/2010
Board
Board of Commissioners
Meeting Type
Regular
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Springfield Free Public Library/Township of Springfield <br />BUSINESS ENTITY DISCLOSURE CERTIFICATION <br />FOR NON -FAIR AND OPEN CONTRACTS <br />Required Pursuant To N.J.S.A. 19:44A -20.8 <br />SPRINGFIELD FREE PUBLIC LIBRARY, TOWNSHIP OF SPRINGFIELD <br />Part I — Vendor Affirmation <br />The undersigned, being authorized and knowledgeable of the circumstances, does hereby certify that the <br /><name of business entity> has not made and will not make any <br />reportable contributions pursuant to N.J.S.A. 19:44A -1 et seq. that, pursuant to P.L. 2004, c. 19 would <br />bar the award of this contract in the one year period preceding on or about April 20, 2010 to any of the <br />following named candidate committee, joint candidates committee; or political party committee <br />representing the elected officials of the Township of Springfield as defined pursuant to N.J.S.A. 19:44A- <br />3 and (r). <br />Ziad Shehady <br />Jerry Fernandez <br />Bart Fraenkel <br />Marc Krauss <br />Hugh Keffer <br />Part II — Ownership Disclosure Certification <br />❑ I certify that the list below contains the names and home addresses of all owners holding 10% or <br />more of the issued and outstanding stock of the undersigned. <br />Check the box that represents the type of business entity: <br />❑Partnership ❑Corporation El Sole Proprietorship ❑Subchapter S Corporation <br />❑Limited Partnership ❑Limited Liability Corporation ❑Limited Liability Partnership <br />Name of Stock or Shareholder I Home Address <br />Part 3 — Signature and Attestation: <br />The undersigned is fully aware that if I have misrepresented in whole or part this affirmation and <br />certification, I and/or the business entity, will be liable for any penalty permitted under law. <br />Name of Business Entity: <br />Signature of Affiant: Title: <br />Printed Name of Affiant : <br />Date: <br />Subscribed and sworn before me this day of <br />,2 <br />(Witnessed or attested by) <br />My Commission expires: <br />(Seal) <br />C:%Program FileslNeevio.ComlDocument ConverterltemplPDFConvert .3395.1.Springfield Free ILS RFP March <br />2010. doc 15 <br />Attachment number 2 <br />F -12 Page 174 <br />
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