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BID NAME <br />FOR BIDS DUE <br />Date: <br />Address: <br />D 2016 or <br />28 <br />O�,OU 1119E <br />vou'o <br />180 <br />Bidder <br />fit) 11 (Firm): 1 i kv k E N V 14o tJ hAEW r,,q L L y U t el <br />9 ry, u, S, s <br />City/State/Zip: Wl VA44+C I /V Ltorelephone Number: (,'00 ) c q:L <br />Agent of Bidder (if Applicable): 7nyZk1{ [9 16 ✓J 1 IZA l <br />When theprospective Contractor is unable to certify to any of the statements below, it shall attach an explanation to this Afjidaviti <br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, <br />CERTIFICATION REGARDING INVESTMENT WITH IRAN, EMPLOYMENT <br />ELIGIBILITY VERIFICATION, NON-DISCRIMINATION COMMITMENT AND <br />CERTIFICATION OF USE OF UNITED STATES STEEL PRODUCTS OR FOUNDRY <br />PRODUCTS <br />(Must be completed for all quotes and bids. Please type or print) <br />STATE OF ) <br />SS: <br />IAJA} ASH COUNTY ) <br />The undersigned Contractor, being duly sworn upon his/hedits oath, affirms under the penalties of perjury <br />that: <br />1. Contractor has not, nor has any other member, representative, or agent of the fnin, <br />company, corporation or partnership represented by him, entered into any combination, <br />collusion or agreement with any person relative to the price to be bid by anyone at such <br />letting nor to prevent any person from bidding nor to induce anyone to refrain from <br />bidding, and that this bid is made without reference to any other bid and without any <br />agreement, understanding or combination with any other person in reference to such <br />bidding. Contractor further says that no person or persons, firms, or corporation has, have <br />or will receive directly or indirectly, any rebate, fee, gift, commission or thing of value <br />on account of such sale; and <br />2. Contractor certifies by submission of this proposal that neither contractor nor any <br />of its principals are presently debarred, suspended, proposed for debarment, declared <br />ineligible, or voluntarily excluded from participation in this transaction by any Federal <br />department or agency; and <br />Ver. 2 — 4/16/12 <br />