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i' ■ <br />date: <br />Address: <br />�E 2021 OR NEWER HORIZONTAL GRINDER <br />Bidder <br />4'iT __. (Firm): <br />�•2f" try �tr 6 � .�n� `c.�,a (, L t <br />City/State/Zip: F c , j ego Telephone Number.2�Leisy Lj of <br />Agent of Bidder (if Applicable): <br />K'hen the prospective Contractor is unable to certify to arty of the statements belaH; it shalt attach an explanation to this <br />Affidavits <br />CONTRACTOR'S NON -COLLUSION AND NON-DEBA.RM]ENT 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 <br />FOUNDRY PRODUCTS <br />(Must be completed for all quotes and bids. Please type or print) <br />STATE Or -Tn1; c, <br />it�M1 courrTY <br />�6V--l690 <br />The undersigned Contractor, being duly sworn upon hisJher/its oath, affirms under the penalties ofperjury <br />that: <br />l . Contractor has not, nor has any other member, representative, or agent ofthe 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 wi 11 receive directly or indirectly, any rebate, fee, gift, commission or thing of value on <br />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 />