2011-328 Planning - DOT Construction, Inc. for bus shelters at DTCC

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Contract No. 1616 County ORANGE Rev. 7-12-10 EXECUTION OF BID NON-COLLUSION AFFIDAVTi', DEBARMENT CERTIFICATION AND GIFT BAN CERTIFICATION JOINT VENTURE (2) or (3) T'he person executing the bid, on behalf of the Bidder, being du]y sworn, solenmly swears (or affirms) that neither he, nor any official, agent or employee of the bidden has entered into any agreement, participated in any collusion, or otherwise taken any action which is in restraint of free competitive bidding in connection with a~ bid or contract, tbai the biddy has not been convicted of violating N.C.G.S. § 133-24 within the last three years, and that the Bidder imends to do the work with its own bonafide employees or subcontractors and is not bidding for the benefit of another contractor. In addition, execution of this bid in the proper manner also constitutes the Bidder's certification of status under penalty of perjury under the laws of the United States in accordance with the Debarment Certification attached, provided that the Debarment Certification also includes any required statements concerning exceptions that are applicable. N.C.G.S § 133-32 and Executive Order 24 prokuliit the offer to, or acceptance by, a~ State Employee of any giR from anyone with a contract with the State, or from any person seeking to do business with the State. By execution of any response in this procurement, you attest, for your entire organization and its employees or agents, that you are not aware that any such gift bas been offered, accepted, or promised by a~ employees of your organization. SIGNATURE OF CONTRACTOR Ins~trctions: 2 Joint Venturers Fill in lines (1), (2) and (3) and execute. 3 Joint Venturers Fill in lines (1), (2), (3) and (4) and execute. On Line (1), fill in the name of the Joint Venture Company. On Line (2), fit] in the name of one of the joint venturers and execute below in the appropnate manner. On Line (3), print ar type the name of the other joint venturer and execute below in the appropriate manner. On Line (4), fill in the name of the third joint venturer, if applicable and execute below in the appropriate manner. (1) Name of Joint Venture (2) Name of Contractor Address as Prequalified Signature of Witness or Attest By Signature of Contractor Print or type Signer's name Print or type Signer's name If Corporafion, afftt Corporate Seal and (3) Name of Contractor Address as Prequalified Signature of Witness or Attest By Signature ofContmctor Print or type Signer's name Print or type Signer's name If Corporation, affix Corporate Seal and (4) Name of Contractor (for 3 Joint Venture only) Address as Prequa]ified Signature of Witness or Attest By Signature of Contractor Print or type Signer's name Print or type Signer's name If Corporafion, affix Corporate Sea! NOTARYSI3AL NOTARYSF,AL NOTARYSF,AL Affidavit must be notarised for Line (Z) Affidavit must be notarized for Line (3) Affidavit must be notarized forLirre (4) Subscribed and sworn to before me this Subscribed and swum to before me this Subscnbed and sworn to before me this -tiny of 20 -tiny of 20_ -day of 20 Signature of Notary Public Signature of Notary Public Signature of Notary Public of County of County of County State of State of State of My Commission Expires: My CommissionExpues: My Commission Expires: