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QUOTE NAME <br />FOR QUOTES DUE <br />Date: /-1r.r, r C?' %� a(1Firm: V Hf.C1' ro n 1' <br />Address: <br />J© l <br />CitylStatelZip:_:14„rti,�1, C fit yd 'phone Number: G 17 K-3 <br />Agent of Firm (if Applicable): <br />Wlreli the prospective Contractor is unable to cert j& to any of dw ° ,, ­iwWs belumo, it sliall attach an explanation to this Affidavit. <br />CONTRACTOR'S NON -COLLUSION Ai'�ll NON -DEBARMENT AFFIDAVIT, <br />CERTIFICATION REGARDING INVESTMENT WITH llt-AN, EMPLOYMENT <br />ELIGIBILITY VERIFICATION, NON-DISCRIMINATION COMMITMENT AND <br />CERTIFICATION OF USE OF UNITED STATES STEEL PRODUCTS OR FOUNDRY <br />PROT)TT( TS. <br />(Must be completed for all quote• l bids. Please type or print) <br />STATE OF� ) <br />SS: <br />Ma r r a to COUNTY ) <br />The undersigned Contractor, being duly sworn upon! !}cr/its oath, affirms under the penalties of perjury <br />that: <br />1. Contractor has not, nor has any o »liner, representative, or agent of the firm, <br />company, corporation or partnership iv; d by him,'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 �;i,icliug nor to induce anyone to refrain from <br />bidding, and that this bid is made withwit rcl'crence to any other bid and without any <br />agreement, undearstanding or combination �%.,ith any other person in reference to such <br />bidding. Contractor further says that no 1'' i or persons, firms, or corporation has, have <br />or will receive directly or indirectly, any c:, fee, gift, commission or thing of value on <br />account of such sale; and <br />2. Contractor certifies by submissi proposal that neither contractor nor any <br />of its principals are presently debacc' tIdcd, proposed for debarment, declared <br />rr <br />ineligible, or voluntarily excluded frow �patioa in this transaction by any Federal <br />department or agency; and <br />3. Contractor has not, nor has any sw- (o, nor an uFliliate of, Contractor, engaged in - <br />investment activities in Iran. <br />