Certification Form

This sworn statement and certification is submitted to CareerSource Palm Beach County by:

Print Name and Title of Individual Certifying as Employer’s Representative

For:

(Print Name and Title of Individual Certifying as Employer’s Representative)

The Employer agrees to and certifies, to the best of the Employer’s knowledge and belief, that:

Employer has and shall comply with the Federal Regulations implementing Executive Order 12505, 12549 and 12689, Debarment and Suspension 29 CFR Part 45, 74, 95 and 98, 2 CFR Part 180, 3 CFR Part 1986-1989 and in doing so provides to CareerSource Palm Beach County, this certification that neither Employer, nor its principals, are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal Department or Agency within a three-year period preceding the effective date of the Agreement No contract shall be awarded to parties listed on the GSA List of Parties Excluded from Federal Procurement or Non-Procurement Programs.

Employer agrees to comply with the provisions of the Byrd Anti-Lobbying Amendment (31 U.S.C. 1352) 29 CFR Part 93. When applicable, if an OJT Agreement is in excess of $100,000, Employer must, prior to contract execution, complete the Certification Regarding Lobbying Form. XX See Appendix A to 29 CFR Part 95 and Appendix A to 45 CFR Part 74 13.

I agree to inform CareerSource Palm Beach County of any change in the information contained in this form.

Signature of Authorized Employer Representative

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Date

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