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0 0 0 JAUMME111 <br />NW -A I'll *o] ,a 1111A.-I -SLO. <br />19101 Wiel IN ILI'M Eel 0 W-11 01 oil Lira] 0111 114M= I'll 9ASA I I <br />• <br />6 <br />" o X I X I I III X 15 o k 331W4 14:4 <br />I I ky, I I o Fill d Eel L <br />BID NAME Janitorial Supplies 2018 <br />FOR BIDS DUE June 12,2018, 9:30 a.m., local time <br />Bidder <br />Date: June 11 _ ('Firm): Powell Tool Supply Inc. <br />Address: 1338 Mishawaka Ave <br />City/State/Zip: South Bend, In 46615 Telephone Number: (574)289-4811 <br />Agent of Bidder (if Applicable) <br />Kevin Reed <br />When the prospective Contractor is unable to certify to any of the statements below, 11shall attach an explanation to this Affidavit <br />In RINI [IM11111530 10111101MM"M "Al 'W3 I D113 !RWIll I I N <br />-, A <br />I W I'll 110-1,11 1 Milk' k-W5 W, 1WV1 I 110 M" <br />%r I IL - I Fk1fll <br />11L'%.� W4U11JA:1'N0§0A: PAN, <br />CERTIFICAT10fl 0Y � i ' 4 1 I, W <br />PRODUCTS <br />(Must be completed for all quotes and bids. Please type or print) <br />STATE OF Indiana) <br />) SS: <br />St. Joseph COUNTY ) <br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of perjury <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 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 />I 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 />