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7.1.A. - Page 20 <br /> BID SOLICITATION FOR LED STREET LUMINAIRES <br /> ATTACHMENT C — EXCLUDED PARTIES SELF - CERTIFICATION <br /> By signing this document, I certify the following; <br /> 1. Please select and complete one of the following: <br /> ❑ Dealership or business: I affirm that neither <br /> (business name) nor any of the principals of <br /> (business name) are identified on the EXCLUDED PARTIES LIST SYSTEM (EPLS), as identified <br /> on the System for Award Management website, www.sam.gov. <br /> ❑ Individual's dba as a business: I affirm that <br /> (responsible party(s)) am /are not identified on the EXCLUDED PARTIES LIST SYSTEM (EPLS), <br /> as identified on the System for Award Management website, www.sam.gov. <br /> ❑ Public entity: I affirm that (public entity) is <br /> not identified on the EXCLUDED PARTIES LIST SYSTEM (EPLS), as identified on the System <br /> for Award Management website, www.sam.gov. <br /> Signed, <br /> Authorized Signature & Title Date <br /> Authorized Signatory Name & Title (print) <br /> Company /Agency Name <br /> Street Address, City, State, Zip Code <br /> PUBLIC WORKS DIVISION 15 <br /> 2013 -2014 LED Street Luminaires <br />