ࡱ> RTKLMNOPQQDbjbjΒeΒeP4P4B B BBBBBB8 C4>C<BMzCzCzCzCzC2MvM$M$V9BMLL^MMBBzCzCZ PPPMdBzCBzCPMPPL@dzCpͰDN@&0M#N#dd#B,hPMMMOMMMMMMMM#MMMMMMMMMP4 nA:ZaBcznik nr 3a do SWZ D10.251.45.E.2024 OZWIADCZENIE dot. art. 5k ust. 1 Rozporzdzenia Rady (UE) 2022/576 z dnia 8 kwietnia 2022 r. w postpowaniu o udzielenie zamwienia publicznego prowadzonego w trybie przetargu nieograniczonego pn.: Dostawa wyrobw medycznych do zabiegw laparoskopowych i elektrochirurgicznych Bdc przedstawicielem(lami) Wykonawcy: (nazwa firmy) O[wiadczam, |e nie podlegam wykluczeniu z postpowania na podstawie art. 5k rozporzdzenia Rady (UE) nr 833/2014 z dnia 31 lipca 2014 r. dotyczcego [rodkw ograniczajcych w zwizku z dziaBaniami Rosji destabilizujcymi sytuacj na Ukrainie (Dz.Urz. UE nr L 229 z 31.7.2014, str. 1), dalej: rozporzdzenie 833/2014, w brzmieniu nadanym rozporzdzeniem Rady (UE) 2022/576 w sprawie zmiany rozporzdzenia (UE) nr 833/2014 dotyczcego [rodkw ograniczajcych w zwizku z dziaBaniami Rosji destabilizujcymi sytuacj na Ukrainie (Dz. Urz. UE nr L 111 z 8.4.2022, str. 1), dalej: rozporzdzenie 2022/576. & & & & & & & & & & & & & & & & . podpis Wykonawcy OZWIADCZENIE DOTYCZCE PODWYKONAWCY, NA KTREGO PRZYPADA PONAD 10% WARTOZCI ZAMWIENIA: [UWAGA: wypeBni tylko w przypadku podwykonawcy (niebdcego podmiotem udostpniajcym zasoby), na ktrego przypada ponad 10% warto[ci zamwienia. W przypadku wicej ni| jednego podwykonawcy, na ktrego zdolno[ciach lub sytuacji wykonawca nie polega, a na ktrego przypada ponad 10% warto[ci zamwienia, nale|y zastosowa tyle razy, ile jest to konieczne.] O[wiadczam, |e w stosunku do nastpujcego podmiotu, bdcego podwykonawc, na ktrego przypada ponad 10% warto[ci zamwienia:& & & & & & & & & & & & & & & & & & & & & & & & & .& & & ..& .& & (poda peBn nazw/firm, adres, a tak|e w zale|no[ci od podmiotu: NIP/PESEL, KRS/CEiDG), nie zachodz podstawy wykluczenia z postpowania o udzielenie zamwienia przewidziane w art. 5k rozporzdzenia 833/2014 w brzmieniu nadanym rozporzdzeniem 2022/576. OZWIADCZENIE DOTYCZCE DOSTAWCY, NA KTREGO PRZYPADA PONAD 10% WARTOZCI ZAMWIENIA: [UWAGA: wypeBni tylko w przypadku dostawcy, na ktrego przypada ponad 10% warto[ci zamwienia. W przypadku wicej ni| jednego dostawcy, na ktrego przypada ponad 10% warto[ci zamwienia, nale|y zastosowa tyle razy, ile jest to konieczne.] O[wiadczam, |e w stosunku do nastpujcego podmiotu, bdcego dostawc, na ktrego przypada ponad 10% warto[ci zamwienia: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & .& & & ..& .& & (poda peBn nazw/firm, adres, a tak|e w zale|no[ci od podmiotu: NIP/PESEL, KRS/CEiDG), nie zachodz podstawy wykluczenia z postpowania o udzielenie zamwienia przewidziane w art. 5k rozporzdzenia 833/2014 w brzmieniu nadanym rozporzdzeniem 2022/576. 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. INFORMACJA DOTYCZCA DOSTPU DO PODMIOTOWYCH ZRODKW DOWODOWYCH: (,02BFHJRTVX˸saR@.#h.h>s5B* KHPJ\ph `#h.h^[5B* KHPJ\ph `h0T5B* KHPJ\ph `#h.h2B5B* KHPJ\ph `#h.h{5B* KHPJ\ph `#h.hc5B* KHPJ\ph `he5B* KHPJ\ph `#h.h(5B* KHPJ\ph `%h.h>s6KHPJ\]nHtH%h.h^[6KHPJ\]nHtHh.h^[6\]h.h{6\]h.hMP6\]02VXZ\v ($d%d&d'dNOPQgd$ -DM a$gd{$ -DM a$gde $*$a$gd{ $*$a$gdgd>s $a$gd{XZ\tv  4 6 ѹnf[TME<h.h]^Jh.h^[5 h.h^[ h.hG)h.h^*phheB*ph&hPu5B* KHPJaJnHph `tH,hehe5B* KHPJaJnHph `tHh.h{6CJaJ h.h{6CJh.h^[6CJh.h{6CJPJ\h.h<6CJh.h<6CJPJ\h.hp5PJ\he5PJ\h.h^[5PJ\  tV $da$gd>s $da$gd{ $da$gd] $da$gd]  $^a$gdPu  $^a$gd]" $d^a$gd{ $a$gd|~tvx~vgXgvMF>F7F h.h>sh.h]6 h.h]h.h]B*phh.h]6B*CJphh.h]6B*CJphh.h]B*CJphh.h]5>* he5>*h.hG)5&h.hG)6CJOJQJ\^JaJ hPu6CJOJQJ\^JaJ&h.h]6CJOJQJ\^JaJh.hG)5\^Jh.h]^J hi:^Jjh.h]0JzU^J~tRVJLNPN.0|1~123333344===򠛓ud`hJ hG`h]CJOJQJ^JaJh.h]CJaJ%jh.h]0JzCJU^JaJh~%h)Q6 h~%6h.h]6Uh.h]5h.h]CJh.h]6CJ h.h{h.h]6B*CJphh.h]B*CJphh.h]5>* h.h] h.h>s"VN0~123333348 $a$gd,"4$d]a$gd~% $da$gd] $da$gdG) $da$gd{$ d^ `a$gd] $da$gd]Wskazuj nastpujce podmiotowe [rodki dowodowe, ktre mo|na uzyska za pomoc bezpBatnych i oglnodostpnych baz danych, oraz dane umo|liwiajce dostp do tych [rodkw: 1) ...................................................................................................................................................... (wskaza podmiotowy [rodek dowodowy, adres internetowy, wydajcy urzd lub organ, dokBadne dane referencyjne dokumentacji) 2) ....................................................................................................................................................... (wskaza podmiotowy [rodek dowodowy, adres internetowy, wydajcy urzd lub organ, dokBadne dane referencyjne dokumentacji) & & & & & & & & & & & & & & . Podpis Wykonawcy  Zgodnie z tre[ci art. 5k ust. 1 rozporzdzenia 833/2014 w brzmieniu nadanym rozporzdzeniem 2022/576 zakazuje si udzielania lub dalszego wykonywania wszelkich zamwieD publicznych lub koncesji objtych zakresem dyrektyw wsprawie zamwieD publicznych, atak|e zakresem art.10 ust.1, 3, ust.6 lit.a) e), ust.8, 9 i10, art.11, 12, 13 i14 dyrektywy 2014/23/UE, art.7 i8, art.10 lit.b) f) ilit. h) j) dyrektywy 2014/24/UE, art.18, art.21 lit.b) e) ilit. g) i), art.29 i30 dyrektywy 2014/25/UE oraz art.13 lit.a) d), lit. f) h) ilit. j) dyrektywy 2009/81/WE narzecz lub zudziaBem: obywateli rosyjskich lub osb fizycznych lub prawnych, podmiotw lub organw zsiedzib wRosji; osb prawnych, podmiotw lub organw, doktrych prawa wBasno[ci bezpo[rednio lub po[rednio wponad 50% nale| dopodmiotu, oktrym mowa wlit.a) niniejszego ustpu; lub osb fizycznych lub prawnych, podmiotw lub organw dziaBajcych wimieniu lub pod kierunkiem podmiotu, oktrym mowa wlit.a) lub b) niniejszego ustpu, wtym podwykonawcw, dostawcw lub podmiotw, naktrych zdolno[ci polega si wrozumieniu dyrektyw wsprawie zamwieD publicznych, wprzypadku gdy przypada nanich ponad 10% warto[ci zamwienia.        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. 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 8z9: <==============>X>>> p#d$*$Ifgd{gd{gd{d $a$gd,"4 & Fd*$gd,"4================@@:AA@ABADAFALANAPA嶣xt`xt'j|h{h{5UmHnHtHuhSp h{hSph{h{KHPJ^J,h{h{B*CJKHPJ\^JaJph%h{h{B*CJKHPJaJphvqqh{h{nHtHh"h,"4'jh{h{5UmHnHtHuhBWh{5jh{UmHnHuhJjhJU>2??@f@@A@ABALANAPAupniingd{gd{]kd|$$Iflt0 #{f%44 lapytG)$ p#d$*$Ifa$gd{ p#d$*$Ifgd{ PAAA0BhBB>CCCfDDDDwl  p# gdi;[kd$$Ifl0 #@&f%44 lapytn~$ p#d$*$Ifa$gdi; p#d$*$Ifgdi; PAD8DDDDDD液h~%h)Q6hJhSp(h`hi;CJKHOJPJQJ^JaJ4h`hi;B*CJKHOJPJQJ\^JaJph1h`hi;B*CJKHOJPJQJ^JaJphvqqDDDD$d]a$gd~%  p#Pgdi;21h:pG). 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WW8Num45z8,/, ^[ WW8Num46z1,/, ^[ WW8Num46z2,/!, ^[ WW8Num46z3,/1, ^[ WW8Num46z4,/A, ^[ WW8Num46z5,/Q, ^[ WW8Num46z6,/a, ^[ WW8Num46z7,/q, ^[ WW8Num46z8,/, ^[ WW8Num47z1,/, ^[ WW8Num47z2,/, ^[ WW8Num47z3,/, ^[ WW8Num47z4,/, ^[ WW8Num47z5,/, ^[ WW8Num47z6,/, ^[ WW8Num47z7,/, ^[ WW8Num47z8,/, ^[ WW8Num48z1,/, ^[ WW8Num48z2,/!, ^[ WW8Num48z3,/1, ^[ WW8Num48z4,/A, ^[ WW8Num48z5,/Q, ^[ WW8Num48z6,/a, ^[ WW8Num48z7,/q, ^[ WW8Num48z8,/, ^[ WW8Num49z1,/, ^[ WW8Num49z2,/, ^[ WW8Num49z3,/, ^[ WW8Num49z4,/, ^[ WW8Num49z5,/, ^[ WW8Num49z6,/, ^[ WW8Num49z7,/, ^[ WW8Num49z84/4 ^[ WW8Num50z1OJ QJ 4/4 ^[ WW8Num50z2OJ QJ 4/!4 ^[ WW8Num50z3OJQJ0/10 ^[ WW8Num51z1CJ,/A, ^[ WW8Num51z2,/Q, ^[ WW8Num51z3,/a, ^[ WW8Num51z4,/q, ^[ WW8Num51z5,/, ^[ WW8Num51z6,/, ^[ WW8Num51z7,/, ^[ WW8Num51z84/4 ^[ WW8Num52z1OJQJ4/4 ^[ WW8Num52z2OJ QJ 4/4 ^[ WW8Num52z4OJ QJ 0/0 ^[ WW8Num53z1KH,/, ^[ WW8Num53z2,/, ^[ WW8Num53z3,/, ^[ WW8Num53z4,/!, ^[ WW8Num53z5,/1, ^[ WW8Num53z6,/A, ^[ WW8Num53z7,/Q, ^[ WW8Num53z8,/a, ^[ 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^[ WW8Num191z7./]. ^[ WW8Num191z8./!]. ^[ WW8Num192z0./1]. ^[ WW8Num192z1./A]. ^[ WW8Num192z2./Q]. ^[ WW8Num192z3./a]. ^[ WW8Num192z4./q]. ^[ WW8Num192z5./]. ^[ WW8Num192z6./]. ^[ WW8Num192z7./]. ^[ WW8Num192z8D/]D ^[ WW8Num193z0B*CJOJQJph6/]6 ^[ WW8Num193z1OJ QJ 6/]6 ^[ WW8Num193z2OJ QJ 6/]6 ^[ WW8Num193z3OJQJD/]D ^[ WW8Num194z0B*CJOJQJph./^. ^[ WW8Num194z2./^. ^[ WW8Num194z3./!^. ^[ WW8Num194z4./1^. ^[ WW8Num194z5./A^. ^[ WW8Num194z6./Q^. ^[ WW8Num194z7./a^. ^[ WW8Num194z8:/q^: ^[ WW8Num195z0 CJOJQJ6/^6 ^[ WW8Num195z1OJQJ6/^6 ^[ WW8Num195z2OJ QJ 6/^6 ^[ WW8Num195z4OJ QJ 2/^2 ^[ WW8Num196z0KH./^. ^[ WW8Num196z1./^. ^[ WW8Num196z2./^. ^[ WW8Num196z3./^. ^[ WW8Num196z4./_. ^[ WW8Num196z5./_. ^[ WW8Num196z6./!_. ^[ WW8Num196z7./1_. ^[ WW8Num196z8H/A_H ^[ WW8Num197z0@B*CJOJQJph./Q_. ^[ WW8Num197z1./a_. ^[ WW8Num197z2./q_. ^[ WW8Num197z3./_. ^[ WW8Num197z4./_. ^[ WW8Num197z5./_. ^[ WW8Num197z6./_. ^[ WW8Num197z7./_. ^[ WW8Num197z8D/_D ^[ WW8Num198z0B*CJOJQJph6/_6 ^[ WW8Num198z1OJ QJ 6/_6 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