EXAMPLE OF APPLICATION for registration SUPPLIERS OF PROCEDURES TO INVITE TO PUR CHASE IN ECONOMY ARTS - Regional Agency for Technology

and Innovation Strada Pro v. per Casamassima, km 3 70010 Valenzano (BA) The sottoscritto________________________________________________________________ ________ _____________________________________il___________________ resident bor n in the City of ______________________________________________________ Provinci a____________________ Street / Piazza___________________________________________ __________n____________, acting as legal representative of _____________________ ______________________________ based in_________________________________________ _____Provincia____________________ Street / Square _____________________________ __________________n________, CAP___________ CF_____________________________ PI__ ______________________ Tel .___________________ Fax____________________e-mail __ __________________ REQUEST to be included in 'list of firms to invite to procure ment of goods, services and jobs in the economy for the following categories (re fer to the types indicated in art. 3 of the Regulation): _______________________ _____________________________________ __________________________________________ _________________________________________ and as such, under its responsibilitie s under DPR No 445/00 and subsequent modifications and additions STATES 1. to be entered in the Register of Companies kept by the Chamber of Commerce of _______ __________ for the following activities ___________________________ed certifies the following 1 SIGNATURE data (for companies based in a foreign state, or enter data or list of registrat ion in the Official State of membership): â ¢ â ¢ â ¢ â ¢ registration number on the reg istration form legal ________________________________ __________________________ ______ ________________________________ Legal representatives (state the names, titles, dates of birth and residence) _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ __ __ __ __

2. that the Company is not in bankruptcy, compulsory liquidation, arrangement an d that there are no pending proceedings for the declaration of one of these situ ations, 3. that its case is not pending in a proceeding for the application of p reventive measures under Article. 3 of Law 27 December 1956, No 1423, or one of the causes provided for by impeding. 10 law 31.5.65 n. 575, 4. which of themselv es were not pronounced convictions have become final, has not been delivered bec ame irrevocable penal sentence or sentences of punishment upon the application r equired under Article. 444 of the CPP, for serious offenses against the State or the Community affecting the professional conduct, which has not been issued the sentence, with a final court for one or more offenses of participation in a cri minal organization, corruption, fraud, money laundering, as defined by Community legislation cited art. 45, paragraph 1, Directive 2004/18 EC, 5. that were not uttered sentences have become final, which was made penal order became irrevocab le nor application of the death sentences of over 2 SIGNATURE request under Article. 444 of the CPP, for serious offenses against the State or the Community affecting the professional conduct, which has not been issued the sentence, with a final court for one or more offenses of participation in a cri minal organization, corruption, fraud, money laundering, as defined by Community legislation cited art. 45, paragraph 1, Directive 2004/18 EC in respect of thos e stopped in the three years prior to the post of technical director or propriet

or (for sole proprietorships), partner or technical director (for partnerships) of general partner or director technical (for a limited partnership); of Directo rs vested with powers of representation or technical director (for any other com pany or consortium) 1 or: acts or claims to have adopted measures for the comple te dissociation of criminal conduct punishable as explained above, held by the o wner or technical director (for sole proprietorships), partner or technical dire ctor (for partnerships) of technical director or general partner (for a limited partnership);€of Directors with powers of representation or technical director (for any other company or consortium) 1 or: states that there are no subjects di scontinued during the three years prior to the post of technical director or pro prietor (for sole proprietors); membership or technical director (for partnershi ps) of technical director or general partner (for a limited partnership); of Dir ectors vested with powers of representation or technical director (for any other company or consortium) 1 6. that did not violate the prohibition laid down by A rticle trustee. Law 17 of March 19, 1990, No 55; 1 Delete the alternatives referred to in paragraph 5, not relevant 3 SIGNATURE 7. he did not commit serious offenses, duly verified, standards for safety and a ny other obligation arising from the employment relationship resulting from data held by the Centre 8. he did not commit a serious error in the exercise of thei r professional activity, proven by any evidence by the contracting station 9. he did not commit violations definitively established from obligations relating to the payment of taxes, according to Italian law or the state where the company i s established 10. than the year before did not make false statements about the r equirements and relevant conditions for participation in tender procedures, resu lting from data held by the Centre 11. he did not commit serious violations, fin ally found the rules of social security contributions, according to Italian law or the State where the company is established 12. (For businesses employing no m ore than 15 employees and 15 to 35 employees who have not made new hires after J anuary 18, 2000) a) his not being subject to the requirements of compulsory recr uitment of Law 68/992; ( For businesses that employ more than 35 employees or 15 to 35 employees when he has a new contract after January 18, 2000) b) be in com pliance with the rules that govern the right to work for the disabled, under Art icle . Law 68/992 17 13. that has not been pronounced sentence for administrativ e responsibility, borne by the Company, which includes the prohibition of bargai ning with the government, according to D. Lgs. 231/01; 2 Delete the alternative, referred to in paragraph 12, which does not affect 4 SIGNATURE 14. that the convictions for which he has benefited not mention are the seguenti 3: _____________________________________________________________________________ __ _____________________________________________________________________________ __ _____________________________________________________________________________ __ _____________________________________________________________________________ __ Or that there are convictions for which has not benefited from menzione3 15. to be informed in conformity with the purposes of Art. 3 D. Decree Law 196/03, t hat personal data collected will be used, including tools, exclusively in the pr

oceedings for which this declaration is made; 16. had achieved in three years 20 03 - 2004 - 2005, categoria4 _______________________, for the following specific turnover of Euro ___________________________________________; for category ____ _______, the following specific turnover of Euro _______________; for category _ __________, the following specific revenues that are to Euro _______________; fo r category ___________, the following specific turnover of Euro _______________. Signature __________________________ NB The declaration must be accompanied by a photocopy, not authenticated, a valid d ocument of identity of the subscriber. 3 4 Delete the alternative, referred to in paragraph 14, the interest identified for each product category for which registration is sought on the specific total tu rnover of the three years 5 SIGNATURE THE DECLARATION BELOW MUST BE SIGNED AND YIELD, PENALTY IF NO ENTRY IN LIST, by the following parties: ⠢ ⠢ ⠢ Members of partnerships, general partners of limite d partnerships; Directors vested with powers of representation if it is other co mpanies. The sottoscritto________________________________________________________________ ________ _____________________________________il___________________ resident bor n in the City of ______________________________________________________ Provinci a____________________ Street / Piazza___________________________________________ __________n____________,€acting as legal representative of ____________________ _______________________________ based in________________________________________ ______Provincia____________________ Street / Square ____________________________ ___________________n________, CAP____________ CF_____________________________ PI ________________________ Tel .___________________ Fax____________________e-mail ____________________ Under Articles 46 and 47 of Presidential Decree 445/00 and subsequent amendments aware of the penalties provided by. 76 of D.P.R. For cases of falsification of documents and false statements indicated: STATE 1) which of themselves are not proceedings are pending for the application of preventive me asures under Article. 3 of Law 27 December 1956, No 1423, or one of the causes p rovided for by impeding. 10 law 31.5.65 n. 575, 2) which of themselves were not pronounced sentences have become final, has not been issued a penal order neithe r become irrevocable judgments on application of the sanction required under art . 444 of the CPP, for serious offenses against the State or the 6 SIGNATURE Communities that affect professional conduct, which has not been issued the sent ence, with a final court for one or more offenses of participation in a criminal organization, corruption, fraud, money laundering, as defined by Community legi slation cited art. 45, paragraph 1 EC Directive 2004/18. Signature _____________ _____________ NB The declaration must be accompanied by a photocopy, not authenticated, a valid d ocument of identity of the subscriber. 7

SIGNATURE