293-22 Exhibit A.pdf

Name: _________________________ Relationship to Proposer: _______________________ Description of Activities: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Duration of Engagement: ____________________ Anticipated Cessation: __________________ Date: _____________________ Proposer Contact Name: _____________________ Contact Phone: _______________________ Number: ________________________ Certification: I, being duly sworn upon my oath, hereby represent and state that the foregoing information and any attachments thereto to the best of my knowledge are true and complete. I attest that I am authorized to execute this certification on behalf of the above referenced person or entity. I acknowledge that the Township of West Orange, State of New Jersey is relying on the information contained herein and thereby acknowledge that I am under a continuing obligation from the date of this certification through the completion of any contracts with the Township to notify the Township in writing of any changes to the answers of information contained herein. I acknowledge that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if I do so, I recognize that I am subject to crin1inal prosecution under the law and that it will also constitute a material breach of my agreement(s) with the Township of West Orange, State of New Jersey and that the Township at its option may declare any contract(s) resulting from this certification void and unenforceable. Full Name (Print): _________________________ Signature: _______________________ Title: _________________________ Date: _____________________________ 56