Project Reference Number: ______________________________________________________

Name of the Project: ______________________________________________________

Standard Form Number: SF-GOOD-11

Revised on: May 24, 2004

Certification of Non-inclusion in the Blacklist

(Date of Issuance)

HON. PEDRO B. ACHARON, JR.

City Mayor

Local Government of General Santos City

City Hall Drive, City Hall Building, General Santos City

Attention : The Chairman

Bids and Awards Committee

Dear Sir / Madame:

In compliance with the requirements of the Local Government Unit of General Santos City - BAC and pursuant to the Implementing Rules and Regulations of Republic Act 9184, the undersigned hereby declares that the firm/company intending to bid for this project, _ (Name of the Bidder)__ is not included in the blacklist of contractors for government of any of its agencies, office, corporations, or LGUs.

Very truly yours,

Name of the Representative of the Bidder

Position

Name of the Bidder

SUBSCRIBED AND SWORN to before me this ______ day of _____________200_____ at General Santos City, Philippines, by the aforenamed affiant who is known to me on the basis of his/her ____________________________ bearing his/her ____________________________ bearing his/her photograph and signature.

Doc. No. _____________;

Page No. _____________;

Book No. _____________;

Series of 200 _____________.