Service Provider Declaration Form

1

SERVICE PROVIDER DECLARATION FORM

1 Identity of the Service Provider:

1.1 Full legal name (in original language and in English):
1.2 Registration number
1.3 Legal form
1.4 VAT number

1.5 Official address:

2 Authorised signatory legally representing the Service Provider:

2.1 Title/Name/Surname:
2.2 Position:

I, the undersigned, authorised to represent the Service Provider organisation, declare that I have read the entire evaluation proposal this Declaration is attached to, and on behalf of my organisation given my agreement to it.

I certify on my honour that the Service Provider is not in one of the situations outlined below:

a)the Service Provider is not bankrupt or being wound up, is not having its affairs administered by the courts, has not entered into an arrangement with creditors, has not suspended business activities, is not the subject of proceedings concerning those matters, and is not in any analogous situation arising from a similar procedure provided for in national legislation or regulations;

b)the Service Provider has not been convicted of an offence concerning professional conduct by a judgment of a competent authority which has the force of res judicata;

c)the Service Provider has not been guilty of grave professional misconduct proven by any means;

d)the Service Provider is in compliance with its obligations relating to the payment of social security contributions and the payment of taxes in accordance with the legal provisions of the country in which it is established or with those of Finland;

e)the Service Provider has not been the subject of a judgment which has the force of res judicata for fraud, corruption, involvement in a criminal organisation, money laundering or any other illegal activity;

f)the Service Provider is not subject to an administrative penalty;

g)the Service Provider has no conflict of interest in connection with the action; a conflict of interest could arise in particular as a result of economic interests, political or national affinity, family, emotional life or any other shared interest;

I further declare that:

a)the Service Provider will inform IOM without delay, of any situation considered a conflict of interests or which could give rise to a conflict of interests;

b)the Service Providerprovided accurate, sincere and complete information within the context of this evaluation proposal;

c)the Service Provideraccepts the standard conditions as laid down in the IOM Service Provider Agreement template (Annex B in the ToR);

d)the Service Provider is directly responsible for the management and coordination, preparation and implementation of the activities contained in this application and is not under any circumstances acting as an intermediary.

The selected Service Provider must be able to provide the proof of the above, as required, prior to signing of the agreement with IOM. If the Service Provider fails to comply with the requirements stated above, it should complete the following section.

Exclusion ground/requirement and explanation:

I acknowledge that the Service Provider may be excluded should it be found guilty of misrepresentation.

Signature of the legal representative of the Co-applicant organisation:

Title (Mr, Ms, Dr, etc.)
Name and Surname
Position in the organisation
Place:
Date :
Signature :