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1616 <br />ContradNo. Rev.7-12-10 <br />cam, ORANGE <br />EXECUTION OF BID <br />NON-COLLUSION AFFIDAVIT, DEBARMENT CERTIFICATION AND GIFT BAN CERTILiTCATION <br />CORPORATION <br />The person executing the bid, on behalf of the Bidder, being duly sworn, solemnly swears (or affirms) that neither he, nor any <br />official, agent or employee of the bidder has entered into any agreement, participated in any collusion, or otherwise taken any <br />action which is in restraint of free competitive bidding in connection with any bid or contract, that the bidder has not been <br />convicted of violating N.GG.S. ,¢ 133-24 within the last three years, and that the Bidder intends to do the work with its own <br />bonafide employees or subcontractors and is not bidding for the benefit of anothea ca~ntractor. <br />1n addition, execution of this bid in the proper manner also constitutes the Bidder's certification of status under penalty of perjury <br />under the laws of the United States in accordance with the Debarment Certification attached, provided that the Debarment <br />Certification also includes any required statements concerning exceptions that are applicable. <br />N. C G S. ~ 133-32 and Exeaitive Order 24 prohibit the offer to, or acceptance by, any State Employee of any gift from anyone <br />with a contract with the State, or from any person seeking to do business with the State. By execution of any response in this <br />procwement, you attest, for your entire organization and its employees or agents, that you are not aware that any such gift has <br />been offered, accepted, or promised by any employees of your organization. <br />SIGNATURE OF CONTRACTOR <br />l~7 ~OrtS~'Y1,CG~{'I on ,1 V1G <br />FuII name of Corporation <br />s~,k so~,_ cG~,.l~~, ti~ ~a~a <br />Address as Pregi <br />Attest ~ y <br />Secrete /Assistant Secre <br />Select appropriate title <br />President~ce PresidentTAssistant V <br />Select appropriate title <br />.games /'~a ve <br />Print or type Signer's name <br />,1,1111111/11~~ <br />'~e~rnrs ~a+!9T,gVO~:`.. <br />Print , Goa,~B~er <br />COREoRA~h~ <br />. ti. ~~ <br />p •.. 2000.0~~2,: <br />AFFIDAVIT MUST BE NOTARIZED <br />Subscribed and sworn to before me this the <br />_~! _ day of (Y1G. 20~. <br />Lf rtd s 5 ~f GGn <br />S' atute of Notary Public <br />of _ (~ CI ~^ ~-P trL~ County <br />State of '~j ~ <br />~ `~~~,Y ~S t t ~`'' . <br />.~~ p5P '~<< ~'~. <br />~~ RR Fri ~: <br />v SNOTAR'~ SEAS, <br />U~ <br />y jOt! B 1.~G,~z <br />My Commission Expires: Q '3 ~ ~ a 015 <br />