Instructions:

1)	Completion of this Certificate is a requirement for consideration to enter in a contract with the OSCE as an Implementing Partner (IP).

2)	The person executing this Certificate on behalf of the potential IP must either be listed as an officially registered agent or present a valid Power of Attorney or similar document granting signing authority.

3)	Items 5 and 6 must be answered only if specifically indicated by the OSCE.

4)	A separate sheet of paper may be attached to this Certificate should there be insufficient space to provide an answer or explanation.  Please indicate the full name of the potential IP and the item number addressed on any separate sheet of paper.

On behalf of (give full name of potential implementing partner) ________________________________

___________________________________________ (hereinafter, “Applicant”), I attest that:

1. There is no undisclosed conflict of interest concerning the planned project (check as applicable):

_____	Neither I, any of the senior managers nor any staff member to be assigned to the planned project is known to be an immediate relative of an OSCE official.

			OR

_____	The following person(s) is/are an immediate relative of an OSCE official (give full name of the person(s) affiliated with the IP, and the full name of any immediate relative(s) who works for the OSCE): 

______________________________________________________________

______________________________________________________________

Note: A conflict of interest (CoI) does not automatically disqualify an applicant from becoming an OSCE implementing partner.  However, the failure to disclose a CoI is a basis for barring the applicant from future consideration or for terminating a concluded Implementing Partner Agreement.  The disclosure obligation also applies to any person later hired to implement the project and who is known to be an immediate relative of an OSCE official.

2. There is no undisclosed co-financing from other donors for the planned project (check as applicable):

_____	Currently the Applicant has neither actual nor pledged funding from any third-party donor, international, humanitarian or other organization for the planned project or for a substantially similar project.

			OR

_____	For the planned project or for a substantially similar project, the Applicant has either actual or pledged funding from the following donor, international, humanitarian or other organization(s) (give the name of each third-party donor, international, humanitarian or other organization, as well as the specific monetary amount(s)): 

______________________________________________________________

______________________________________________________________

Note: The OSCE accepts only original receipts from implementing partners, stamping them “Paid by the OSCE” in order to eliminate duplicate funding.  Any receipt marked as paid by a third-party donor, international, humanitarian or other organization will be disallowed.

3. There is a commitment to legal compliance (check as applicable):

_____	The Applicant complies with all applicable national legislation, including but not limited to tax and labour law.

			OR

_____	The Applicant is unable to comply with one or more requirements due to the following reason(s):

______________________________________________________________

______________________________________________________________

4. The Applicant has or will acquire the capacity to be able to submit narrative and financial reports in an agreed format and on a timely basis (check as applicable):

_____	One or more staff members to be assigned to the project possesses professional competence in preparing and submitting the required documentation.

			OR

_____	The Applicant understands and agrees that acquisition of professional competence in submitting required documentation constitutes both a requirement under the project and one of the fundamental measurements of its success.

	Note: An applicant lacking such competency is eligible for capacity building projects.

				(Programme Manager: Check here if the planned project is defined as “high risk” according to paragraph 13 of FAI 15).	

5. Answer only if the above box is checked:

_____	The Applicant possesses all of the licenses, certificates and insurance coverage required to carry out the planned project activity.

OR

_____	The Applicant possesses all of the licenses, certificates and insurance coverage required to carry out the planned project activity, except for the following (also indicate whether any license, certificate or insurance coverage lacking can be acquired prior to project implementation):

______________________________________________________________

______________________________________________________________

				(Programme Manager: Check here if the planned project is budgeted at EUR 250,000 or more).	

6. Answer only if the above box is checked:

_____	The Applicant either has or will open a separate bank account to be used exclusively for financial matters relating to the project.

		OR

_____	The Applicant is unable to open a separate bank account for the following reason(s):

______________________________________________________________

______________________________________________________________

By signing this Certificate, I certify that the above information is true and accurate.  I further understand and agree that the submission of false information may result in the barring of the Applicant from future consideration for funding by the OSCE or in termination of a concluded Implementing Partner Agreement.

Seal:				Signed:		__________________________________

				Name:		__________________________________

Title:		__________________________________

				Date:		__________________________________