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<br /> ,/' <br /> 1/1 ¡-- <br /> Fonn 4732.... <br /> P8ge 2 <br /> , " . , <br /> 3. Prohibitions Against Contracts with Certain Former Employees <br /> A.. Has the potential contractor endJ;;arryd ~ employees been employed by DHS 'wÜhin the last 12 months? ....0 Yes 0 No <br /> If uNo," skip to number .c. <br /> S. Is a former employee, or an organization controlled fm part or whole) by a fanner employee, 8PP¥ng for this contract? . . 0 Yes 0 No <br /> C. Has (or will) the former empk)yee(s) be paid to aid in the cfeyek pment of or the attempt tD obtain the proposed contract? 0 Yes 0 No <br /> .. ,- ',-'", ' .. . <br /> D- Does tne- proposed contract relate to a pcogmm or set'Vice in which the potentia! contractor/employee(s) . <br /> (while with DHS) was djrectty concemad or had administratiYe responsibility? . . . . . . . . . . . . . . . . . . . . . . . . . . . ',' . . 0 Yes 0 No <br /> .. "No," skip to number.c) <br /> E. 1e answer is "Yes" to "S" and "C," or ~'C" and uC," provide the fom1er DHS employee's name and indicate whether he earned <br /> .an annualized gross salary of $28,836 or more at the time he left employment with DHS. <br /> NAME $28.836 or _7 <br /> DYes ONe <br /> '. -Dyes ONe <br /> Dyes ONe <br /> ~. Ftnanciallnterest-Provide the name and other requested information about any person who is owner <in part or whole}, officer, director, <br /> employee, or consultant employed or associated with your organization and who <br /> A. was a member of the DHS Board and who left on or after September 1,1987; <br /> B. is now a member of the DHS Board; <br /> C. was an employee of DHS and who left on or after September 1,1987; <br /> D. is now an employee, of DHS; or <br /> E. is related in a manner specified in Question 2 of Form 4732 (rtems A-N), to the person(s) in items A, B, C, or 0 immediately above. ., <br /> NAME Owns 1 ~ « more 7 $2,500 0<" mon! <br /> 1mtestment7 <br /> - Dyes DNa DYes DNa <br /> DYes DNa Dyes ONe <br /> Dyes DNa DYes ONe <br /> CERTIFICATION <br /> I certify that the information above and on the reverse Is complete, true and correct ,to the best of my knowledge. I under- <br /> stand that lack of full, true and complete di~losure may œ grounds for withholding payment for delivered services and may <br /> cause contract termination. <br /> Name of PotentIal Non-9QVemmentaJ Contracto< I Contract No, I SociaJ Security No, or VIN <br /> DescnptlOrl of Contracted Serw:elltllm <br /> I Print ()( Type Name I <br /> SlÇnatur~AU1nonzed AepresentatIW D8te <br />