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<br />CITY OF S,0(UTii,,t-BEND INDIA A
<br />SELLER'S B10FOR SALE OR LE��,—E, OF MATERle�L C,
<br />4,1D NAME Water, Treatmevik Ch,emicalsi 2:1020-2,0214--- . . . . . ............ ................. -1--
<br />FOR..... . .... . . ......
<br />04/06/20 Blddr aPolydyne Inc.
<br />Date. (Rrm)'
<br />dresChernicalplant Rd..
<br />Ad;&: . ......... .. ............... . .. .............. ..... ---- ... . ...... ..... . . .............................................
<br />cltylstart e,/.Zlp�' Riceboro, GA 31,323 Telephone Number, -20,35 . ....
<br />,Agent of Bidder (if Appi[cable): "",N/A . . ................
<br />. . ..... . ..............
<br />Whem theprospective Comfildefor, is unable to etarfifP to any of dur slaremeno, heloov, It shallastoehan explanodam to this Affidalok.
<br />CONTRACTOWS NON -COLLUSION AND NON. DEHARMENTAFFIDAVIT,
<br />CERTIFICAT10N REGARDINC INVFSTM ENT14 111AN, EMPLOYMENT
<br />ELIGIBILITY VERIFICATION NON-DISCRIMINATION COMMITMEN r T AND
<br />CEWFIFICATION OF USE OFUNITED STATES STEIEL PRODUCT'S OR FOUNDRY
<br />PRODUCTS
<br />(Must be airnpleted for all quotes, and, bids,. Please type or pfint)
<br />STATE ()F, Georgia
<br />........ ......... --- . .. ...
<br />), S's:
<br />L-iberlY COUNTY
<br />'rho undersigned Contractorl being duly swom upon lus/herhtg oath, affirms underthe penalties, of'perjury
<br />thdt:
<br />I . Contractor has not, nor has any other member, representative, or agent of the fim,
<br />company, corporation or paitiership represented by him, entered into any combination,
<br />Collusion or, agreement with any person, mlative to, the pr�ice to lie bid by anyone at such
<br />lotting not to Prratany person firom bidding nor to induce anyone to refrain frorn
<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 farther says, that no person, or persons, firms,, or co,iVoration has,, have
<br />oir will receive directi: or indirectly, any rebate, fee, gib, commission or thue
<br />ing ofvalon
<br />y
<br />account of such sale; and
<br />2. Contractor eertifies by suhaxis sion of this proposal, that neither contrac'tor nor all
<br />ofits p6ricipals are presently debarred, seas ptildedproposed for debarment, declared
<br />ineligible, or voluntarily excluded from participation in'this transaction by any Federal
<br />department or agtmcy; and
<br />3 Contractor has not, nor has any, successor to, nor an a,11iffiate of*, Contractuir, engagiW ift
<br />investincrit activities in kan.
<br />a� For purposes of this !fie ltification, "Irai.P,,imearrs tile govemment oftrait and, arty apilcy
<br />or instrutnentality of Iran,, or as othawise, defined, at Ind, Code § 5-22:-16.5-5, as
<br />amended from Berne -to -time.
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