eligible for, or to bid on, submit a proposal for, or enters into or renews, a contract for goods and services. If you have obtained an exemption from the certification requirement under the Iran Contracting Act, please fill out the information below, and attach documentation demonstrating the exemption approval. Vendor Name/Financial Institution Federal ID Number (or n/a) By (Authorized Signature) Printed Name and Title of Person Signing Date Executed Executed in County and State of
eligible for, or to bid on, submit a proposal for, or enters into or renews, a contract for goods and services. If you have obtained an exemption from the certification requirement under the Iran Contracting Act, please fill out the information below, and attach documentation demonstrating the exemption approval. Vendor Name/Financial Institution Federal ID Number (or n/a) By (Authorized Signature) Printed Name and Title of Person Signing Date Executed Executed in County and State of