Application Form - Houston Advanced Research Center

advertisement
Texas Environmental Research Consortium
Required Proposal Forms
The following are forms to be completed as part of the proposal package. The forms included
are:











Application Form: HARC Form 52
Instructions for Application Form: HARC Form 52 Instructions
Key Contacts Form: HARC Form 53
Additional Key Contacts: HARC Form 54
Itemized budget: HARC Form 55 (found in a separate file as it is an excel
spreadsheet)
Abstract: HARC Form 56
Current and Pending Projects: HARC Form 57
Certification Regarding Lobbying, Suspension and Debarment, Single Audit: HARC
Form 58
List of Authorized Personnel: HARC Form 59
Certification regarding use of Certified Labs
TERC Conflict of Interest Policy and Certification
Revised: 04/08
Texas Environmental Research Consortium
Application Form – HARC Form 52
Complete all of the following information including signature.
Please insert the project number and title for the proposal being submitted:
________ (project number: title)
1. Applicant Information
Legal Name of Organization:
Organizational Unit:
Address (street, city, state, zip code):
Principal Investigator
Telephone Number:
E-mail address:
Administrative Contact:
Employer Identification Number (EIN):
Telephone Number:
E-mail address:
2. Type of Applicant (enter appropriate letter):
___
a. University
c. National Laboratory
b. Profit Organization
d. Non-profit Organization
e. Other (specify):
____________________________
3. Type of Application:
____ Revision
___ New
____ Continuation
4. Total Funding Requested:
$__________________
5. Proposed Project Schedule:
____________
Start Date
____ RFQ
___________End Date
6. Is this proposal being submitted to another funding source?
____Yes _____ No
If yes, list organization:___________________________
7. To the best of my knowledge and belief, all data in this application are true and correct. The document has been
duly authorized by the governing body of the applicant and the applicant will comply with Federal certifications
regarding Debarment, Suspension and other Responsibility Matters from covered transactions by any Federal
department or agency. The applicant also certifies to the best of his/her knowledge or belief that it is in
compliance with the Federal Lobbying Certification for Contracts, Grants, Loans and Cooperative Agreements
and that any subsequent subcontracts made from this award, should this contract be awarded, are subject to these
same assurances.
Typed Name of
Authorized Representative
Title
Signature of Authorized Representative
Date Signed
Telephone number
__________________________________ ______________
HARC use only
Date and Time Received: __________________ Received By: ________________________________
Revised: 04/08
Texas Environmental Research Consortium
Instructions for HARC Form 52
Top section: If proposal is in response to an RFP, list the project code and title that corresponds to your proposal.
Section l. Applicant information
Provide the legal name of the institution or organization that is submitting this proposal
Provide the complete mailing address for this institution/organization
Provide the Employer Identification Number (EIN) provided by the IRS
Provide the name of the organizational unit or department under which this proposal is being developed
Provide the name, telephone number and e-mail address of the Principal Investigator (P.I.) for this proposal
Provide the name, telephone number and e-mail address of the person identified as the project Administrative
Contact
Section 2. Type of Applicant
Specify the type of institution or organization submitting this proposal.
If other than those listed please specify the type of institution or organization
Section 3. Type of Application: Specify if this is a new application, a continuation of previous research conducted,
or a revision of an application previously made to HARC.
Section 4. Total of Funding Requested: Provide the total amount of funding being requested in this proposal.
Section 5. Proposed Project Schedule:
Note the expected start date for initiation of this project.
Note the expected date for completion of this project. This should reflect the date on which you expect to be able to
submit completed work to HARC.
Section 6. Is this project being submitted to another funding source?
If you or your sponsoring organization has already submitted or plan to submit this project in expectation of
receiving funding from another organization please acknowledge by marking yes or no. If yes, please list the
funding organization.
Section 7. Authorization and Assurances
Read carefully the information contained in Section 7 prior to signing as the Authorized Representative:
 That all the information contained in the proposal as submitted is true and correct to the best of your knowledge.
 That your signature equates with your governing body’s agreement to participate.
 That the governing body is assuring compliance with Federal Certification regarding Debarment, Suspension
and other Responsibility Matters from covered transaction by any Federal Department or Agency.
 That the applicant certifies to the best of his/her knowledge that the agency is in compliance with the Federal
Lobbing Certification for Contract, Grants, Loans and Cooperative Agreements, and that any subsequent
subcontract made from this award, should this contract be awarded, is subject to the same assurances.
Please provide the name, title, and telephone number of the duly Authorized Representative typed in the space
provided.
The Authorized Representative shall sign and date the application.
This original signed hard copy shall be submitted to HARC.
Revised: 04/08
Texas Environmental Research Consortium
Key Contacts Form – HARC 53

Authorized Representative: Original awards and amendments will be sent to this individual for review and acceptance, unless
otherwise indicated.
Name:
Title:
Complete Address:
Phone Number:
Fax Number:
E-mail Address:

Payee: Individual authorized to accept payments
Name:
Title:
Complete Address:
Phone Number:
Fax Number:
E-mail Address:

Administrative Contact: Individual to contact concerning contracting and administrative matters:
Name:
Title:
Phone Number:
Fax Number:
E-mail Address:

Financial Contact: Individual to contact concerning financial questions relative to invoices submitted:
Name:
Title:
Phone Number:
Fax Number:
E-mail Address:

Principal Investigator: Individual responsible for the technical completion of the proposed work.
Name:
Title:
Phone Number:
Fax Number:
E-mail Address:
Revised: 04/08
Texas Environmental Research Consortium
Additional Key Contacts (use as many sheets as needed) – HARC Form 54

Major Co-Investigator: Individual responsible for the completion of major portions of the proposed work.
Name:
Title:
Phone Number:
Fax Number:
E-mail Address:

Major Co-Investigator: Individual responsible for the completion of major portions of the proposed work.
Name:
Title:
Phone Number:
Fax Number:
E-mail Address:

Major Co-Investigator: Individual responsible for the completion of major portions of the proposed work.
Name:
Title:
Phone Number:
Fax Number:
E-mail Address:

Major Co-Investigator: Individual responsible for the completion of major portions of the proposed work.
Name:
Title:
Phone Number:
Fax Number:
E-mail Address:

Other: Individual responsible for _______________________________ (describe).
Name:
Title:
Phone Number:
Fax Number:
E-mail Address:
Revised: 04/08
Texas Environmental Research Consortium
Budget Form and Justification Instructions
Allowable costs are those costs deemed allowable in the Texas Uniform Grant Management
Standards (UGMS) (1 Texas Administrative Code §5.141- 5.167), the TCEQ Allowable
Expenditures Guidelines and all applicable state rules and law.
Describe the basis for calculating the personnel, costs, travel, equipment, supplies, contractual
support, and other costs identified in the itemized budget and explain the basis for their
calculation. The budget justification must not exceed two consecutively numbered (bottom
center), 8.5x11-inch pages with 1-inch margins.
A. Personnel: List name and position, the percent of time budgeted to this project, and the rate
or rates used to calculate personnel cost. Rates may include fringe benefits or burdened hourly
rates.
B. Travel: Travel costs, including per diem, will be reimbursed only in the amount of actual
costs, up to the maximum allowed by law for Texas state employees' travel at the time the cost is
incurred. Reimbursement for costs will not exceed actual costs and in no case will they exceed
the market price in the local area where the Contract Activity is performed. Travel by volunteers
will not be reimbursed.
Specify travel and purpose (i.e., fieldwork, attendance at meetings, etc.) for the proposed work.
Provide basis for cost estimates (i.e., number of travelers, airfare, per diem, miles traveled,
mileage allowance, hotel rates, etc.).
C. Equipment: List, describe, and justify any equipment required. Equipment is defined as any
item costing $5,000 or more with a useful lifespan of more than one year. Allowable items will
be limited to research equipment necessary and not available to conduct this project.
D. Supplies: List and justify all supply items and provide the cost basis for the amount
requested.
E. Subcontracts: Describe the need and basis for subcontractors listed. Provide the cost basis
for budgeted amount.
F. Other Costs: List and justify other direct cost items and describe the cost basis for budgeted
amount.
G. Indirect Cost Rate: There is a 15% cap on indirect costs and only those institutions with a
negotiated IDC rate may request this. Proof of a federally negotiated IDC rate must be provided
at the time of contracting.
Revised: 04/08
Texas Environmental Research Consortium
Abstract – HARC Form 56 – One Page Limit
Project Code:
Investigators:
Institution/Organization:
Project Period:
Title:
Total Budget:
Revised: 04/08
Texas Environmental Research Consortium
Current and Pending Projects – HARC Form 57
List other projects on which the Principal Investigator and other key personnel are currently
working or projects that are anticipated within the time frame of the proposed project.
Name and Dates of Project
Funding Source
Position on Project
(PI, Co-PI, Collaborator, Consultant)
and % time committed
Revised: 04/08
Texas Environmental Research Consortium
HARC Form 58
CERTIFICATION REGARDING LOBBYING
Houston Advanced Research Center
Certification for Contracts and Agreements
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) None of these Federal or State of Texas appropriated funds have been paid or will be paid to employ,
as a regular full-time or part-time or contract employee, by or on behalf of the undersigned, to any
person for influencing or attempting to influence an officer or employee of an agency, a Member of
Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection
with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal
loan, the entering into of any cooperative agreement, and the extension, continuation, renewal,
amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.
(2) None of these State of Texas appropriated funds have been or will be used to pay, on behalf of the
agency or an officer or employee of the agency, membership dues to an organization that pays part or all
of the salary of a person who is required by the Texas Ethics Commission under Chapter 305 to register
as a lobbyist.
(3) None of these State of Texas funds have been or will be used to pay a person or entity required to
register with the Texas Ethics Commission under Chapter 305; or any partner, employee, employer,
relative, contractor, consultant, or related entity of a person or entity that is required to register with the
Texas Ethics Commission under Chapter 305; or a person or entity that has been or will be hired to
represent associations or other entities for the purpose of affecting the outcome of legislation, agency
rules, ordinances, or other governmental policies.
(3) Violation of this certification subjects the undersigned to reduction of amounts appropriated for
administration in an amount not to exceed $100,000 for each violation and/or become ineligible to
receive additional State of Texas funds.
(3) The undersigned shall require that the language of this certification be included in the award
documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants,
loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This
certification is a material representation of fact upon which reliance was placed when this transaction
was made or entered into. Submission of this certification is a prerequisite for making or entering into
this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required
certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for
each such failure, if such funding is Federal.
____________________________________________
Name and Title of Authorized Representative
____________________________________________
Signature of Authorized Representative
Date____________
Revised: 04/08
Texas Environmental Research Consortium
Suspension and Debarment Certification
(1) The prospective lower tier participant certifies, by submission of this proposal, that neither it
nor its principals are presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded from participation in this transaction by any Federal or
State department or agency.
(2) Where the prospective lower tier participant is unable to certify to any of the statements in
this certification, such prospective participant shall attach an explanation to this proposal.
(3) All lower tier participants shall be required to sign this form.
Name of Applicant
___________________________________________________________
Name of Program
___________________________________________________________
____________________________________________
Name and Title of Authorized Representative
_____________________________________________
Signature of Authorized Representative
______________
Date
Revised: 04/08
Texas Environmental Research Consortium
Single Audit Certification
The applicant is not a local government or non-profit and therefore is not required to submit an
annual single audit. The applicant understands and agrees, however, that the TCEQ may
contract for or conduct an audit of a grant recipient’s grant-funded program.
The applicant is a local government or non-profit and currently expends combined state funds of
less than $500,000 per year and, therefore, is not required to submit an annual single audit. The
applicant understands and agrees, however, that the TCEQ may contract for or conduct an audit
of a grant recipient’s grant-funded programs.
The applicant is a local government or non-profit and currently expends state funding of
$500,000 or more per year and, therefore, is required to submit an annual single audit to the
Grant Manager by an independent auditor made in accordance with UGMS. The applicant
understands and agrees that, in addition to the single audit requirements, that the TCEQ may also
contract for or conduct an audit of a grant recipient’s grant-funded program.
__________________________________________
Signature of Authorized Representative
______________
Date
Revised: 04/08
Texas Environmental Research Consortium
Personnel Authorized to Charge on the Project and Rate
HARC Form 59
Please list all personnel that will be working on this project.
Project Number:
P.I. Name:
Organization:
It is anticipated the personnel to be paid on the above project include:
Personnel
Hourly Rate (Salary only)
Revised: 04/08
Texas Environmental Research Consortium
HARC Form 60
CERTIFICATION REGARDING USE OF CERTIFIED LABS
Houston Advanced Research Center
Certification for Contracts and Agreements
If any laboratory produces data under this Contract and the preparation of such data commences on or
after July 1, 2008, the laboratory must be accredited by TCEQ according to Title 30 Texas
Administrative Code (TAC) Chapter 25 (relating to Environmental Testing Laboratory Accreditation
and Certification) Subchapters A and B as amended, for the matrices, methods, and parameters of
analysis, unless TCEQ agrees in writing to allow one of the regulatory exceptions specified in 30 TAC
25.6.
The undersigned certifies, to the best of his or her knowledge and belief, that (please check only one):
(1) Applicable data may be produced under this contract and the laboratory has been
accredited by TCEQ according to Title 30 Texas Administrative Code (TAC) Chapter
25 (relating to Environmental Testing Laboratory Accreditation and Certification)
Subchapters A and B as amended, for the matrices, methods, and parameters of
analysis.
(2) Applicable data may be produced under this contract and TCEQ has agreed in writing
to allow one of the regulatory exceptions specified in 30 TAC 25.6 for the laboratory.
Copy of waiver is provided.
(3) Applicable data may be produced under this contract through the procurement of
services from a third-party laboratory that has been accredited by TCEQ according to
Title 30 Texas Administrative Code (TAC) Chapter 25 (relating to Environmental
Testing Laboratory Accreditation and Certification) Subchapters A and B as amended,
for the matrices, methods, and parameters of analysis.
Name of certified laboratory: _____________________________________________
(4) Applicable data may be produced under this contract and the HARC project manager
and TCEQ liaison agree that the laboratory techniques to be employed in this project
are not subject to the certification requirements. Copy of documentation is provided.
(5) There will be no applicable data produced under this contract.
____________________________________________
Signature of Authorized Representative
Date____________
____________________________________________
Name and Title of Authorized Representative
Name of Organization and Subcontract number
Revised: 04/08
Texas Environmental Research Consortium
Texas Environmental Research Consortium
Conflict of Interest Policy
Section 1.
Purpose
The Texas Environmental Research Consortium (TERC) is a 501(c)(3) nonprofit
organization that is dedicated to improving air quality throughout the State of Texas by
improving policymakers’ and scientists’ understanding of ozone and other pollutants to assure
the development of scientifically valid and cost effective air quality policies. It is also TERC’s
mission to facilitate the development, commercialization and certification of new technologies to
maximize emission reductions.
It is the policy of TERC to adhere rigorously to the highest moral and ethical standards.
Its mission and responsibilities are to be administered in a professional manner that assure
maximum consideration relative to ethical, moral and legal conduct of its affairs.
Section 2.
A.
Definitions
Conflicts of Interest. A Conflict of Interest exists when a real or perceived private
interest of a Director, Officer, Contractor, Consultant, Committee Member or
other employee is in conflict with the interests of TERC, as when such individual
receives improper personal benefit as a result of his or her position with TERC or
when the individual has other duties, loyalties, responsibilities or obligations that
are, or may be viewed as being, inconsistent with those of TERC.
B.
Interested Person.
Any Board Member, Officer, Member of a Committee,
Contractor or Consultant with Board-held or delegated powers who has a direct or
indirect financial interest in a TERC matter.
C.
Financial Interest.
A person has a financial interest if the person has, directly
or indirectly, through business, investment or family:
an ownership or investment interest in any entity with which TERC has a
transaction or arrangement or which stands to benefit from TERCsponsored projects; or
a compensation arrangement with TERC or with any entity or individual with
which TERC has a transaction or arrangement or which stands to benefit
from TERC-sponsored projects; or
3.
a potential ownership or investment interest in, or compensation
arrangement with, any entity or individual with which TERC is
negotiating a transaction or arrangement or which stands to benefit from
TERC-sponsored projects.
The payment or receipt of items such as political contributions, dues payments, legal and
consulting fees and the like shall not constitute receipt of an improper personal benefit unless
such items directly relate to TERC business or projects.
D.
Family.
Family includes spouse, parent, children, siblings, grandparents,
grandchildren, sons and daughters-in-law, and brothers and sisters-in-law.
Revised: 04/08
Texas Environmental Research Consortium
Section 3.
Conflict of Interest Policy. The activities of TERC’s Directors, Officers,
Employees, Committee Members, Contractors and Consultants are expected to fully comply with
all applicable laws, rules and regulations. Additionally, Directors, Officers, Employees,
Committee Members, Contractors and Consultants of TERC may not personally benefit from his
or her relationship or employment with TERC except through compensation received directly
from TERC. Conflicts of Interest are prohibited as a matter of TERC policy. Each Director,
Officer, Employee, Committee Member, Contractor or Consultant is to manage his or her
personal and professional affairs in such a way as to avoid conflicts of interest and to avoid
creating the appearance of a conflict of interest. TERC’s research and technology decisions must
be based solely on the best interests of TERC, without regard to personal, family, business or
other extraneous considerations. Relationships and arrangements which may be the basis of a
conflict of interest are:
A.
Direct or indirect financial interest in a company which maintains a business
contracting or subcontracting relationship with TERC, without advance written
disclosure to and approval by the Chairman of the Board of Directors and/or
TERC’s Executive Director.
Receipt of salary, fees or any other direct or indirect remuneration for services from a
company which maintains a business, contracting or subcontracting relationship
with TERC or which stands to benefit from TERC-sponsored projects;
Employment, whether public or private, in an organization which may impact the
operations of TERC in a regulatory, business, contracting or subcontracting
manner, without advance written disclosure to and approval by the Chairman of
the Board of Directors of TERC and/or TERC’s Executive Director.
Receipt of any gifts, favors, or preferential treatment that might reasonably tend to affect
the discharge of official duties of an officer, member of the Board of Directors,
contractor, subcontractor or Committee Member of TERC.
Securing privileges or exemptions for oneself or another because of one’s service as an
officer, member of the Board of Directors, contract, subcontractor or Committee
Member of TERC.
Disclosure or use of confidential information for personal gain. Confidential information
includes, but is not limited to, financial, personnel, intellectual and technology
information regarding contractors, subcontractors, applicants and all organizations
that maintain a direct or indirect relationship with TERC.
Use of TERC’s personnel, materials, assets, or other resources for direct or indirect
personal benefit.
Revised: 04/08
Texas Environmental Research Consortium
Section 4.
A.
Procedures.
Duty to Disclose By Director or Committee Member.
1.
A Director or Committee Member shall have the affirmative duty to
disclose any possible conflict of interest at the time it arises as well as in
the annual conflict of interest statement that must be completed.
2.
In connection with any actual or possible conflicts of interest, a Director
or Committee Member must disclose the existence of his or her financial
interests and all material facts relating thereto to the Board of Directors
and Members of Committees with Board-delegated powers considering
the proposed transaction or arrangement.
B.
Determining Whether a Conflict of Interest Exists. After disclosure of the
financial interest and all material facts relating thereto, and after any discussion
thereof, the interested person shall leave the Board or committee meeting while
the financial interest is discussed and voted upon. The remaining Board or
committee members shall decide if a conflict of interest exists.
C.
Addressing a Conflict of Interest. When the Board or a Board committee is
considering a transaction, arrangement or project that could result in a conflict of
interest for a particular member, the following steps must be taken:
D.
1.
The Member with a potential conflict shall leave the meeting during the
discussion and vote relating to the transaction, arrangement or project that
would result in a conflict of interest; and
2.
The members present shall determine, by majority vote, whether the
transaction, arrangement or project is in TERC’s best interest and for its
own benefit, and whether it is fair and reasonable to TERC.
Violations of the Conflicts of Interest Policy.
1.
If the Board or Committee has reasonable cause to believe that a member
has failed to disclose actual or possible conflicts of interest, it shall inform
the member of the basis for such belief and afford the member an
opportunity to explain the alleged failure to disclose.
2.
If, after hearing the response of the member and making such further
investigation as may be warranted in the circumstances, and the Board or
Committee determines that the member has, in fact, failed to disclose an
actual or possible conflict of interest, it shall take appropriate disciplinary
and corrective action.
Section 5.
Duty to Disclose by TERC’s Executive Director and Consultant(s). TERC’s
Executive Director and Consultant(s) are strictly prohibited from engaging in any activity that
constitutes a real or perceived conflict of interest. Real or perceived conflicts of interest shall be
brought to the immediate attention of the Chairman of the Board of Directors. The Executive
Revised: 04/08
Texas Environmental Research Consortium
Director and Consultant(s) shall fully resolve any real or perceived conflicts of interest as
prescribed by the Chairman of the Board of Directors and in the best interests of TERC.
Section 6.
Duty to Disclose by the Houston Advanced Research Center. The Houston
Advanced Research Center (HARC) serves as TERC’s Research and Technology Manager.
Accordingly, HARC is integrally involved in administering TERC’s air quality research and
technology programs. TERC compensates HARC for the services it provides. HARC, its
employees, contractors and consultants are strictly prohibited from engaging in any activities that
would constitute a real or perceived conflict of interest. HARC shall have the duty to disclose
any potential real or perceived conflict of interest involving itself, its employees, contractors and
consultants in writing to TERC’s Executive Director and Board Chairman. HARC shall assure
prompt resolution of any real or perceived conflict of interest as prescribed by the Executive
Director and Board Chairman. HARC and its employees, contractors and consultants also shall
complete TERC’s Conflict of Interest Certification form annually.
Section 7.
Failure to Resolve Conflicts of Interest. The failure of TERC’s Executive
Director, Consultant and HARC to resolve conflicts of interest as described above may result in
immediate termination of these persons’ or entities’ employment or contractual relationships
with TERC.
Section 8.
Bribery. Directors, Officers, Employees, Consultants And Contractors are strictly
forbidden from offering, promising or giving money, gifts, loans, rewards, favors or anything of
value to anyone, including governmental officials, employees, agents or other intermediary(ies)
(either inside or outside the United States) which is prohibited by law. Those paying a bribe may
subject TERC and themselves to civil and criminal penalties. Accordingly, no improper
payments will be tolerated.
Section 9.
Records of Proceedings. The minutes of the Board and all committees with
Board-delegated powers shall contain:
A.
Names of Persons with Financial Interest. The names of the persons who
disclosed or otherwise were found to have a financial interest in connection with
an actual or possible conflict of interest, the nature of the financial interest, any
action taken to determine whether a conflict of interest was present, and the
Board’s or committee’s decision as to whether a conflict of interest in fact existed.
B.
Names of Persons Present. The names of the persons who were present for
discussions and votes relating to the transaction, arrangement or project, the
content of the discussion, including any alternatives to the proposed transaction,
arrangement or project, and a record of any votes taken in connection therewith.
Section 10.
Annual Certification. In addition to disclosing and acting on conflicts of interest
as they arise, TERC’s Board Members, Officers, Employees, Consultants and Contractors shall
complete a Certification Statement at the end of each year acknowledging receipt of a copy of
TERC’s Conflict of Interest Policy and certifying compliance with this policy.
Attachment:
TERC’s Conflict of Interest Certification Form.
Revised: 04/08
AUSTIN: 980000.30000: 327627v2
Texas Environmental Research Consortium
Texas Environmental Research Consortium
Conflict of Interest Policy Certification Statement
I hereby acknowledge receipt of a copy of the Conflict of Interest Policy of the Texas
Environmental Research Consortium (“TERC”), which applies to my professional
and personal dealings with TERC. By executing this Certification Statement, I
acknowledge that I have read and understand TERC’s Conflict of Interest Policy and
agree to be bound by all provisions therein. I further acknowledge that I am now
and all relevant times have been in compliance with its provisions.
Signature
Date
Print Name
Revised: 04/08
Texas Environmental Research Consortium
Texas Environmental Research Consortium
Conflict of Interest Policy Certification Statement
I hereby acknowledge receipt of the Conflict of Interest Policy of the Texas
Environmental Research Consortium (“TERC”), which applies to the professional
and personal dealings of employees within our organization who are working on
projects funded by TERC through the Houston Advanced Research Center (HARC).
By executing this Certification Statement, I acknowledge that I have forwarded this
policy and received certification statements from those employees involved with a
TERC project. The executed Certification Statements will be on file in our grants
office for auditing purposes.
I further acknowledge that our organization is now and all relevant times have been
in compliance with its provisions.
Signature
Date
Print Name
_____________________________________
Organizational Name
Revised: 04/08