ࡱ> QdCbjbjvv'ee*_*_mmmmmmmm8md2nTmnnnnnwx<x /111111$UQmxww@xxUmmnnxRmnmn/x/gѭn.AHy08{tѭѭm_xxxUU}zxxxxxxxxxxxxxxxx*_ Hl:d10.251.67.e.2024 ZaBcznik nr 4 do SWZ Wykonawca: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & (peBna nazwa/firma, adres) reprezentowany przez: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & (imi, nazwisko, stanowisko/podstawa do reprezentacji) Zamawiajcy: COPERNICUS PL Sp. z o.o. ul. Nowe Ogrody 1  6 80-462 GdaDsk O[wiadczenie wykonawcy skBadane na podstawie art. 125 ust. 1 ustawy z dnia 10 wrze[nia 2019 r. Prawo zamwieD publicznych (dalej jako: ustawa Pzp), DOTYCZCE PRZESAANEK WYKLUCZENIA Z POSTPOWANIA Na potrzeby postpowania o udzielenie zamwienia publicznego pn.: Wykonanie dokumentacji projektowej dla inwestycji pn.  Adaptacja pitra VII budynku A Szpitala [w. Wojciecha na potrzeby administracji SpBki prowadzonego przez Copernicus PL Sp. z o.o., o[wiadczam, co nastpuje: O[wiadczam, |e nie podlegam wykluczeniu z postpowania na podstawie art. 108 ust. 1 ustawy Pzp. O[wiadczam, |e zachodz w stosunku do mnie podstawy wykluczenia z postpowania na podstawie art. & & & & . ustawy Pzp (poda majc zastosowanie podstaw wykluczenia spo[rd wymienionych w art. 108 ust. 1). Jednocze[nie o[wiadczam, |e w zwizku z ww. okoliczno[ci, na podstawie art. 110 ust. 2 ustawy Pzp podjBem nastpujce [rodki naprawcze: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & ..& & & & & & & & O[wiadczam, |e nie podlegam wykluczeniu z postpowania na podstawie art. 7 ust. 1 ustawy z dnia 13 kwietnia 2022 r. o szczeglnych rozwizaniach w zakresie przeciwdziaBania wspieraniu agresji na Ukrain oraz sBu|cych ochronie bezpieczeDstwa narodowego. O[wiadczam, |e wszystkie informacje podane w powy|szych o[wiadczeniach s aktualne i zgodne z prawd oraz zostaBy przedstawione z peBn [wiadomo[ci konsekwencji wprowadzenia zamawiajcego w bBd przy przedstawianiu informacji. & & & & & & & ..& & & & & & & & & & & (podpis) d10.251.67.e.2024 ZaBcznik nr 5 do SWZ Wykonawca: & & & & & & & & & & & & & & & & & & & & & & & & & & & & (peBna nazwa/firma, adres) reprezentowany przez: & & & & & & & & & & & & & & & & & & & & & & & & & & & & (imi, nazwisko, stanowisko/podstawa do reprezentacji) Zamawiajcy: COPERNICUS PL Sp. z o.o. ul. Nowe Ogrody 1  6 80-462 GdaDsk O[wiadczenie wykonawcy skBadane na podstawie art. 125 ust 1 ustawy z dnia 10 wrze[nia 2019 r. Prawo zamwieD publicznych (dalej jako: ustawa Pzp), DOTYCZCE SPEANIANIA WARUNKW UDZIAAU W POSTPOWANIU  "H J L b Ѻѣ{gT>+$h hN^CJKHPJaJnHtH*h hN^5CJKHPJ\aJnHtH$h h!5>*CJPJ\]aJ&h h!5CJOJQJ\^JaJ&h h,*5CJOJQJ\^JaJ&h h8RX5CJOJQJ\^JaJ-h h^5;CJKHOJQJ\^JaJ-h h,*5;CJKHOJQJ\^JaJ-h hr^5;CJKHOJQJ\^JaJ-h h!5;CJKHOJQJ\^JaJ J L b  @ & D yy~d^~`gd!}dx^}`gd!~d*$7$8$H$^~`gd!z*$7$8$H$]zgd!A*$7$8$H$]AgdN^B*$7$8$H$]BgdN^ *$7$8$H$gdN^$a$gd,*  @ B D F v v ꗋlU?U,$h hN^CJ KHPJaJ nHtH*h hN^5CJKHPJ\aJnHtH-h hN^5>*CJKHPJ\aJnHtH%h hN^5>*KHPJ\nHtHh h!5CJaJh h!5CJaJ*h h!5CJKHPJ\aJnHtH$h hN^CJKHPJaJnHtH'h hN^>*CJKHPJaJnHtH*h h!6CJKHPJ]aJnHtH*h hN^6CJKHPJ]aJnHtHD F v  v \ ^ |~ $a$gd0G $K`Ka$gd[#_ $da$gd0G$dh*$7$8$H$a$gdN^$dhx*$7$8$H$a$gdN^$*$7$8$H$a$gd0G$dhx*$7$8$H$a$gdN^ X \ ^ z|~ ͭp\QC4Q&h hN^6CJ]aJh hN^56CJ\aJh hN^5CJ\aJh hN^CJaJ&h h[#_5CJOJQJ\^JaJ?h h,*5B* CJ KHOJPJQJ\^JaJnHph `tH9h8RX5B* CJKHOJPJQJ\^JaJnHph `tH?h,*h,*5B* CJKHOJPJQJ\^JaJnHph `tH h h[#_CJOJQJ^JaJ h hHmCJOJQJ^JaJ h hN^CJOJQJ^JaJ h(,8:ګژĂkTkT=-h h^5;CJKHOJQJ\^JaJ-h hr^5;CJKHOJQJ\^JaJ-h h,*5;CJKHOJQJ\^JaJ*h hU?6CJKHPJ]aJnHtH$h hN^CJKHPJaJnHtH0h hr^CJKHOJPJQJ^JaJnHtH*h hr^6CJKHPJ]aJnHtH$h hr^CJKHPJaJnHtH$h hN^CJ KHPJaJnHtH~c$ d*$7$8$H$^ `a$gd8RX$d*$7$8$H$a$gdr^$dh*$7$8$H$a$gd42$ & Fd*$7$8$H$a$gd8RX$d*$7$8$H$^a$gdr^gdr^$d*$7$8$H$a$gdr^$ & Fd*$7$8$H$a$gd#]; Z\rH2P||~d^~`gd!}dx^}`gd!~d*$7$8$H$^~`gd!z*$7$8$H$]zgd!A*$7$8$H$]AgdB*$7$8$H$]Bgd *$7$8$H$gdgd8RX:$,Z\rH轧~hRh>~h(*h hr^5CJKHPJ\aJnHtH'h hUq>*CJKHPJaJnHtH*h h!6CJKHPJ]aJnHtH*h hUq6CJKHPJ]aJnHtH$h hUqCJKHPJaJnHtH*h hUq5CJKHPJ\aJnHtH*h h!5CJKHPJ\aJnHtH&h h8RX5CJOJQJ\^JaJ-h h,*5;CJKHOJQJ\^JaJ-h h8RX5;CJKHOJQJ\^JaJNPR22222ҿ||ecXMB7h h!CJaJh h6CJaJh hHmCJaJh hUqCJaJU-h hUq5>*CJKHPJ\aJnHtH*h h%5CJKHPJ\aJnHtH*h hUq5CJKHPJ\aJnHtH-h hUq5>*CJKHPJ\aJnHtH%h hUq5>*KHPJ\nHtHh h!5CJaJh h!5CJaJ*h h!5CJKHPJ\aJnHtHPR222333344d*$7$8$H$gdr^$dh*$7$8$H$a$gd6 $K`Ka$gd,* $a$gd0G$x*$7$8$H$a$gd0G$*$7$8$H$a$gd0G$x*$7$8$H$a$gd0GNa potrzeby postpowania o udzielenie zamwienia publicznego pn.: Wykonanie dokumentacji projektowej dla inwestycji pn.  Adaptacja pitra VII budynku A Szpitala [w. Wojciecha na potrzeby administracji SpBki o[wiadczam, co nastpuje: INFORMACJA DOTYCZCA WYKONAWCY: O[wiadczam, |e speBniam warunki udziaBu w postpowaniu okre[lone przez Zamawiajcego w IX ust. 1 pkt 2 SWZ & & & & & .& & . (miejscowo[), dnia & & & & .& & . r. INFORMACJA W ZWIZKU Z POLEGANIEM NA ZASOBACH INNYCH PODMIOTW (je|eli dotyczy): O[wiadczam, |e w celu wykazania speBniania warunkw udziaBu w postpowaniu, okre[lonych przez Zamawiajcego w IX ust. 1 pkt 2 SWZ, polegam na zasobach nastpujcego/ych podmiotu/w: ..& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & .& & , w nastpujcym zakresie: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & (wskaza podmiot i okre[li odpowiedni zakres dla wskazanego podmiotu). & & & & & .& & . (miejscowo[), dnia & & & & .& & . r. OZWIADCZENIE DOTYCZCE PODANYCH INFORMACJI: O[wiadczam, |e wszystkie informacje podane w powy|szych o[wiadczeniach s aktualne i zgodne z prawd oraz zostaBy przedstawione z peBn [wiadomo[ci konsekwencji wprowadzenia Zamawiajcego w bBd przy przedstawianiu informacji. & & & & & .& & . (miejscowo[), dnia & & & & & & . r. & & & & & & & ..& & & & & & & & & & & (podpis)      PAGE   COPERNICUS Podmiot Leczniczy Sp. z o.o. ul. Nowe Ogrody 1-6, 80-803 GdaDsk Centrala telefoniczna: 58 76 40 100 Sekretariat Biura Zarzdu: 58 76 40 340, 58 76 40 142, fax 58 30 21 416www.copernicus.gda.pl sekretariat.kopernik@copernicus.gda.pl NIP: 583-316-22-78, REGON: 221964385, KRS: 0000478705 Sd Rejonowy GdaDsk-PBnoc w GdaDsku KapitaB zakBadowy 272.598.000,00 PLN wpBacony w caBo[ci Rachunek bankowy: 72 1440 1101 0000 0000 1099 1064  COPERNICUS Podmiot Leczniczy Sp. z o.o. ul. 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