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<br />MORG-111 . I IIKIM�IFLW.11=12
<br />Bidder,
<br />Dke.'. 04108120 (Firm)try Inc,
<br />Ad&essrue Chem a] P'l rut Ned_
<br />GitylState/Zip' l'eborrjGAj132,3..—. TeMphone Number., (�,912)880,-m2!03,5
<br />_Rc
<br />Agent of Bidder (ifApplicable),, _N/A . . .......... ..........
<br />Pffien the Plivapeedve Contntrfor is, 110'adliple 10 kvOff flrfflvft
<br />j�, so any of be/v Ps� irstj W/ (ottireh, an, explan adon to th k 4f
<br />CON1RACTOR"S TUHN-COLLUS10N AND NON-DEBAIkNIENT AFFIDAVIT',
<br />CERTHA.CATION RECARDING [WESTME N'l''WITH IRAN, EMPLOYNI EN'T
<br />ELIGIBJUTY NIEWFICATION, NOPOMSCRINUNAPON (,`0MM1TNWWNTAND
<br />CER.7171FICATION 0F USE OF UN117ED STATFS S'I'EEL PRODUC-17S O.'R FOUNDRY
<br />PRODUCTS
<br />Qdmsi be mupicte,,d fkwull quotesand bids, Please type or prit"01
<br />STATE OF APH P
<br />)SS.'
<br />Ij!?prty __COUNTY
<br />The undersigned CoMman, haiing dkol. P sWorn upon lWaKs nab. affirtAIS onder the ponallics, 4:47 t,)e1jury
<br />that::
<br />L CoWractor has not, nor has airy Other member,, represeujtafi ve, or agent oftbe
<br />C(rn r pany, CorP01,114% or partnership re,selite(j, by him., cnl,,�ered ivilo any caj.,nbinaticio,
<br />Mission or aptonent with any pentm reladve to the 1wice to be bid by anyotic at SuS
<br />Ming nor W"Mmit any JICI'son from, laidding not to induce, anyone [c) refirain, ftoni
<br />bidding; aml Wat this bid i,, irimdc "rithout relrcnc-- to any wber bild and ivilh(wl any
<br />agrccnici,,it, undersuand,ing,� or Qorrihinntlon milb arly other Person, i!rr reference to, stwh
<br />biddiing. Clontnictor 00her says that mi person or pursonq Onns. ar corporation has, IlavL
<br />or w-01 reocive directly or itidirectly, any rehate, fee, gill, co tn in iss ion or thing of vakic on
<br />account oF such sak; and
<br />2. contractor ce-i,(ifics by submi,,,sioti of this, propwal that neifli,�r contVICCtorilr0l" fluly
<br />of its principals are, Pyesently debarred, �:uspended, proposed for debarinent, declaveO
<br />inefigible:, or vol'untaxily excluded fi-on, jja.jrticipa&n in Ods transactioii. by any Federal
<br />CIPMUmm (w aguwy; and
<br />3, c,oirtrirctur Ws nm; nudws any successor to, an affifiaw of, Cootractor, en,agL:d in
<br />inventirmul antivhIs in Iran.
<br />at For puqmw nf ddY Claincattoll, aNrnd, -any,11z �Jwy
<br />m inshinnewUlty of Inut or no Wavise defined al: fird. C,ode, § 5-22-16.5•-5, as
<br />anrended fiv-jni
<br />
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