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QUOTE NAME <br />FOR QUOTES DUE <br />Date: -ir-• j ti af117 Firm: i/�/a Cz 3p Z �r <br />Address <br />: �� �: �— <br />CitylStatelZip:sA; pl y� l�phone Nrrmber: 3 1 35 l/ 4) <br />Agentof Firm (if Applicable):/e r _ <br />When theprospective Contractor is unable to cer16(y to any of'11w ,. ,,,,,!ixw .s belo)p, it shrill attach an explanation to flits Affl4avit.. <br />CONTRACTOR'S NON -COLLUSION Ai 'D 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 />PRODTWTS <br />(Must be completed for all ctuotr -� A bids. Please type or print) <br />STATE OF �— ) <br />� ) SS: <br />IV)a f-1�d ,n COUNTY ) <br />The undersigned Contractor, being duly sworn utsorr ! '! r/its oath, affirms under the penalties of perjury <br />that: <br />1. Contractor has not, nor has any o ' .,c jnber, representative, or agent of the firm, <br />company, corporation or partnership r: `._d by hire, entered into any combination, <br />collusion or agreement with any person ; c to the price to be bid by anyone at such <br />letting nor to prevent any person from ';,,!ding nor to induce anyone to refrain from <br />bidding, and that this bid is made witho it reference to any other bid and without any <br />agreement, understanding or combinations With any other person in reference to such <br />bidding. Contractor further says that too 1" n or persons, firms, or corporation has, have <br />or will receive dixectly or indirectly, any : c, fee, gift, commission or thing of value on <br />account of such sale; and <br />2. Contractor certifies by submissi propos,,rl slut neither contractor nor any <br />of its principals are presently debarrec! � r,clecl, proposed for debarment, declared <br />ineligible, or voluntarily excluded froin : ;anon in this transaction by any Federal <br />department or agency; and <br />3. Contractor has not, nor has anysuc its, nor an affiliate of, Contractor, engaged in - <br />investment activities in Iran. <br />