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�.- Y OF SOUTH , ,; N.S <br />INDIANA <br />SELLER'S BID FOR SAL CA'LEASE OF MATERIALS <br />t7k wmr <br />BID NAME _Water Treatment Chemicals 2019-2020 <br />0199:30AM Local Time <br />FOR BIDS DUE Aprrl 23 2219, , <br />, 1 65 <br />Bidder <br />Date: April 18, 2019 (Firm): PVS Minibulk, Inc. <br />Address: 10900 Harper Avenue <br />City/State/Zip: Detroit, Telephone Number. 200 <br />MI 48213 � — 313 921-1 _— <br />Agent of Bidder (if Applicable): Laura Bainbridge / 773-517-3234 <br />When the prospective Contractor is unable to certify to any of the statements below, it shall attach an explanation to this Afrdavit. <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 lope or print) <br />STATE OF —MICHIGAN ) <br />SS; <br />E COUNTY ) <br />F WAY N.... <br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of pei jury <br />that: <br />1. Contractor has not, nor has any other member, representative. or agent of the firm, <br />corrupany, corporation or partnerskip represented by hirer, entere(l into any corrrhination, <br />collusion or agreement with any person relative to the price to be bid by anyoure at such <br />letting nor to prevent any person from bidding nor to induce anyone to refrain from <br />bidding, Ind that this bid is made witlIOUt reference to any other bid and without ally <br />agreement, understanding or combination with airy other person ir"r rel"ererlce to such <br />bidding. Contractor ltrrtlrer° Says that 110 person or persons, lirins, or corporation lets, breve <br />ol° will receive directly or indirectly, any rebate, f"car„ gift, conn'lrssion or thing of"value Oil <br />account of such sale; and <br />2. Contractor certifies by submission of this Proposal Lilot neither contractor nor any, <br />of its principals are presently debarred, suspended, l:)r oposed lOr debarment, declared <br />ineligible, or voluntarily excluded from participation in this transaction by any Federal <br />depar( ent 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 />a. For Inirposes oft 11is Ceitit"jeation, "Iran„ "leans the government of Iran and any agency <br />or instrumentality of Irarl, or as otherwise defined at Ind. Code § 5-22-16.5-5, as <br />amended fro,,, tptt�c-r��-ti�rae. <br />