Attachment 4: F 4.15.2 Self declaration

F 4.15.2 Rev. 21 Oct 2025

F 4.15.2

Declaration in lieu of the affidavit

Rev. 21 October 2025

Companies and Self-Employed Workers

INSTRUCTIONS:

To be completed by CONTRACTORS or SELF-EMPLOYED WORKERS Fill in only one of the two forms, depending on the applicable case:  Form A1 – Companies:
• Complete all fields with company information
• Fill in the checklist items with the required information in the grey boxes (letters d), e)) • Attach all documents listed at the bottom of the form • Indicate place and date
• Apply company stamp and signature
• Return this self-certification to the Contracting Office (31 CONS) or to the requester of the work or service (Client).  Form A2 – Self-Employed workers:
• Complete all fields with company information
• Attach all documents listed at the bottom of the form • Indicate place and date
• Apply stamp and signature
• Return this self-certification to the Contracting Office (31 CONS) or to the requester of the work or service (Client).

For clarification:
31 FW/CCPP, Prevention and Protection Office [Safety and Occupational Health – FN requirements, D.Lgs 81/08] Email: [email protected]
Comm. +39 0434 307722
Hours: Mon-Fri 8.30-12.30/13.30 -17.30
Aviano Air Base, Bldg. 1472

F 4.15.2 Rev. 21 Oct 2025

A1 – COMPANY

DECLARATION IN LIEU OF THE AFFIDAVIT

(D.P.R. 28.12.2000, n. 445 – S.O. n. 30 alla G.U. n. 42 del 20.02.2001) in quality of Employer

The undersigned
of the Company
address
phone

VAT/ P.IVA

Pec
Fiscal Code/ CF
INPS Assurance Position/s

PAT INAIL

Emplyment Contract / Contratto Collettivo Nazionale di Lavoro (C.C.N.L.) applied

aware of the criminal penalties applicable in the event of false statements, pursuant to Articles 47 and 76 of Presidential Decree 28 December 2000, No. 445, and Article 11, paragraph 3 of Presidential Decree 20 October 1998, No. 403, having regard to Articles 26 (paragraph 1) and 90 (paragraph 9), and Annex XVII of Legislative Decree No. 81/2008,

DECLARES

a)

That the company is duly registered in the Business Register (Registro delle Imprese), with a Corporate Purpose relevant and appropriate to the type of work assigned.
b) That all obligations regarding occupational health and safety, as required by Legislative Decree No. 81/08 and subsequent amendments, have been fulfilled.
c) That the Risk Assessment Document (DVR) has been prepared. d) That the Responsible of the Prevention and Protection Service (RSPP) has been appointed. e) That the Occupational Health Physician has been appointed (Medico Competente).