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BID NAME <br />FOR BIDS DUE <br />pec T — Eighteen (18) More or Less Now Heavy Duty Mobile Lifting Sysi <br />2017 at 9:30 <br />Bidder <br />Date: 71 i G7/ ), .7 _.(Firm): Fos al- A5 !Q_ I F1i ��_� �►V G <br />Address: { h N I p(-N fc <br />Cit /state2i 10+ ( A <br />Y A' � s-" �(� Telephone Number: <br />Agent of Bidder (if Applicable): M_eH 8E7L_ --oSj <br />When -rho prospecffve Co*1PaeYor fs unable to cerf fy ra any of lire .4faftenteuris �SefiFmv, ft shOff affaeh an erpldrrdrlon fn M1s Affld av& <br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, <br />CERTIFICATION REGARDING INVESTMENT WITH MAN, 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 j.Ljp[ !a�f� ) <br />SS. <br />PCJR-16 COUNTY ) <br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of peg ury <br />that: <br />1, Contractor has not, nor has any other member, representative, or agent of the firm, <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 laid by anyone at such <br />letting nor to prevent any person from bidding not to induce anyone to refrain from <br />bidding, and that this bid i~r made without reference to any other bid and withmd 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 />3. Contractor has not, nor has any successor to, nor an affiliate of, Contractor, engaged in <br />investment activities in Iran, <br />4 <br />