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O44o'J eF <br />3G <br />E� <br />u c <br />y;. reuse - j <br />� t855 <br />BID NAME: <br />FOR BIDS DUE: <br />Spec AA - Two (2) More or Less 2016 or Newer Refurbished Medic Units <br />July 26, 2016; 9:30 a.m., Local Time <br />Bidder 1 <br />Date: 7-a2Sa01b (Firm): gado <br />Address: 3800 A%dk,wo// .! 4,.ee� r: <br />City/State/Zip: (ems—�,�.OL S3ia3 Telephone Number: Cr7y ) tll&- 4C7&,6 <br />Agent of Bidder (if Applicable): <br />When the prospective Contractor is unable to certify to any of the statements below, it shall attach an explanation to this Affidavit <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 />STATE OF <br />(Must be completed for all quotes and bids. Please type or print) <br />SS: <br />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 />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 />5 <br />