ࡱ> KMHIJE4%bjbj ehj ihj i|dd        8M 4  M  "0"# cLeLeLeLeLeLeL$ORhLE #"""##L  L$$$#  cL$#cL$$E0EH @Bs#GPOLL0MmGR#RHEHEHR H\$###LL$"###M####R#########dc : ZaBcznik numer 4 do SWZ Wykonawca: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & ..& & & & & & & & & ............ (peBna nazwa/firma, adres, w zale|no[ci od podmiotu: NIP/PESEL, KRS/CEiDG) reprezentowany przez: & & & & & & & & & & & & & & & & & & & & & & & .............& & & & & & & & & & & & & ......... (imi, nazwisko, stanowisko/podstawa do reprezentacji) O[wiadczenie wykonawcy / wykonawcy wsplnie ubiegajcego si o udzielenie zamwienia skBadane na podstawie art. 125 ust. 1 ustawy z dnia 11 wrze[nia 2019 r. Prawo zamwieD publicznych (dalej jako ustawa Pzp), DOTYCZCE PRZESAANEK WYKLUCZENIA Z POSTPOWANIA Na potrzeby postpowania o udzielenie zamwienia publicznego pn.  Dostawy szww chirurgicznych , o[wiadczam(y), co nastpuje: OZWIADCZENIA DOTYCZCE WYKONAWCY: O[wiadczam(y), |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 pkt 1, 2 i 5 ustawy Pzp). Jednocze[nie o[wiadczam, |e w zwizku z ww. okoliczno[ci, na podstawie art. 110 ust. 2 ustawy Pzp podjBem nastpujce [rodki naprawcze i zapobiegawcze: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & . & & & & & & & & & & & & & & & & & & & & & & & & $*08:NPN P | ^ ` ŷzzk\zzQkkBh6CJOJQJ^JaJhe6h &B*phh &>*CJOJQJ^JaJh &6CJOJQJ^JaJhOCJOJQJ^JaJh &CJOJQJ^JaJh &h &5CJOJQJ^JaJhQ{CJOJQJ^JaJhCJOJQJ^JaJ hP#h CJOJQJ^JaJhSCJOJQJ^JaJh;4ECJOJQJ^JaJhrACJOJQJ^JaJ8:PP | ` b d  j l h $d`a$gd;4E $da$gdX $da$gdqVi Ad]AgdX Bd]BgdX dgdX dhgd ` b d |    j l }o_N@h;4ECJOJQJ^JaJ hk|h &CJOJQJ^JaJhk|h5>*OJQJ^Jhk|h &>*OJQJ^JhH5>*OJQJ^Jh;4E5>*OJQJ^Jh _<5>*OJQJ^JhHhH5>*OJQJ^JhqVi5>*OJQJ^JhqVihqVi5>*OJQJ^JhqVihH5>*OJQJ^JhQ{6CJOJQJ^JaJhH6CJOJQJ^JaJ  ( * , . f h j :ՊveWF>-- h$h &CJOJQJ^JaJh$h &5 h4h>Y>CJOJQJ^JaJhCJOJQJ^JaJ hk|h &CJOJQJ^JaJ&hS>*B* CJOJQJ^JaJphp#hWhS>*CJOJQJ^JaJ h 5CJOJQJ\^JaJ&hFhS5CJOJQJ\^JaJ&hFh/$5CJOJQJ\^JaJ&hFh;4E5CJOJQJ\^JaJ,hh% >*B* CJOJQJ^JaJphph j tv """0#}}}}+$d[$a$gdX"$d^a$gdS"$d^a$gd7 "$da$gd7"$ & F 8d^`a$gdqVi$d-DM a$gdX$d`a$gd4 :jprtv "n & & ŴŴwiXJhSCJOJQJ^JaJ hShmaeCJOJQJ^JaJhSCJOJQJ^JaJ h4hqViCJOJQJ^JaJUhmaeCJOJQJ^JaJhCJOJQJ^JaJhjCJOJQJ^JaJ hqVihqViCJOJQJ^JaJh7CJOJQJ^JaJhqViCJOJQJ^JaJh;4ECJOJQJ^JaJ h$hHCJOJQJ^JaJ& & & & & & & & & & & & & & & & & & .& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & O[wiadczam, |e nie zachodz w stosunku do mnie przesBanki wykluczenia 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 (Dz. U. poz. 835). Uwaga: W przypadku gdy nie zachodz w stosunku do Wykonawcy okoliczno[ci o ktrych mowa w o[wiadczeniach nale|y wykre[li tre[ o[wiadczenia. Zamawiajcy rwnoznacznie ze skre[leniem o[wiadczenia bdzie rozumiaB nie uzupeBnienie jego tre[ci 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.      PAGE 2  !!!!!"""""0#$$$$$$%%%%% % %%%ʹۨۗ~jjVNJJNJJNJJNJJhZjhZU&hjhmae6CJOJQJ]^JaJ&hjhk6CJOJQJ]^JaJh$hk5 hX6CJOJQJ]^JaJ hH6CJOJQJ]^JaJ hmae6CJOJQJ]^JaJ h;4E6CJOJQJ]^JaJ hO6CJOJQJ]^JaJ&h$hH6CJOJQJ]^JaJ hS6CJOJQJ]^JaJ0#$$$%%% %%%&%(%*%.%0%2%4%%&&$a$+$d[$a$gdj%%% %"%$%&%(%*%,%.%0%2%4%&hjhmae6CJOJQJ]^JaJhZh;4Ejh;4EUmHnHtHuhiAhSCJ^JaJmHnHuhiACJ^JaJjhiACJU^JaJ ? 0&P 0p1h:p. 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