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DOH CONTRACT #: CLH18249 <br /> <br />2018-2020 2021 Consolidated Contract Page 15 of 17 <br />B. Where the prospective contractor is unable to certify to any of the statements in this certification, such prospective <br />contractor shall attach an explanation to this contract. <br /> <br />AUTHORIZED SIGNATURE REQUIRED <br />SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL TITLE <br />PLEASE PRINT OR TYPE NAME: <br />ORGANIZATION NAME: (if applicable) DATE