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STATE OF OALWORNIA <br />DARFIIR CONTRACTING ACT CERTIFICATION <br />DOS PD 1 (Rev. 12110) <br />DEPARTMENT OF GENERAL SERVICES <br />PROCUREMENT DIVISION <br />Pubile Contract Code Sections 10475-10481 applies to any company that currently or <br />within the previous three years has had business activities or other operations outside <br />of the United States. For such a company to bid on or submit a proposal for a State of <br />California contract, the company must certify that it is either a) not a scrutinized <br />company; or b) a scrutinized company that has been granted permission by the <br />Department of General Services to submit a proposal. <br />If your company has not, within the previous three years, had any business activities <br />or other operations outside of the United States, you do not need to complete this <br />form. <br />OPTION #1 - CERTIFICATION <br />If your company, within the previous three years, has had business activities. or other <br />operations outside of the United States, in order to be eligible to submit a bid or <br />proposal, please insert your company name and Federal ID Number and complete the <br />certification below. <br />I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that a) the <br />prospective proposer/bidder named below is not a scrutinized company per Public <br />Contract Code 10476; and b) I am duly authorized to legally bind the prospective <br />proposerlbidder named below. This certification is made under the laws of the State of <br />CompanyNandorName (Printed) <br />By (Authorized Signature) <br />Printed Name and Title of Parson Signing <br />Federal Q Number <br />ORTION #2 —WRITTEN PERMISSION FR IW DGS <br />Pursuant to Public Contract Code Section 10477(b), the Director of the Department of <br />General Services may permit a scrutinized company, on a case -by -case basis, to bid <br />on or submit a proposal for a contract with a state agency for goods or services, if it is <br />in the best interests of the state. If you area scrutinized company that has obtained <br />written permission from the DGS to submit a bid or proposal, complete the information <br />below. <br />Pago 1 of 2 <br />