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1616 <br />ContcactNo. <br />~~~, ORANGE <br />xe~. ~-iz-to <br />EXECUTION OF BID <br />NON-COLLUSION AF~7DAVTT, DEBARMENT CERTIFICATION AND GIFT BAN CERTIFICATION <br />INDIVIDUAL DOING BUSINESS UNDER A FIRM NAME <br />The person executing the bid, on behalf of the Bidder, being duly sworn, solemnly swears (or affirms) that neither <br />he, nor any official, agent or employee of the bidder has entered into any agreement, participated in any collusion, or <br />otherwise taken any action which is in restraint of free competitive bidding in connection with any bid or contract, <br />that the bidder has not been convicted of violating N.C G.S. §.133-24 within the last three years, and that the Bidder <br />intends to do the work with its own bonafide employees or subcontractors and is not bidding for the benefit of <br />another contractor. <br />In addition, execution of this bid in the proper manner also constitutes the Bidder's certification of status under <br />penalty of perjury under the laws of the United States in accordance with the Debarment Certification attached, <br />provided that the Debarment Certification also includes any required statements concerning exceptions that are <br />applicable. <br />N.C.G.S ~ 133-32 and Executive Order 24 prohibit the offer to, or acceptance by, any State Employee of any gift <br />from anyone with a contract with the State, or from any person seeking to do business with the State. By execution <br />of any response in this procurement, you attest, for your entire organization and its employees or agents, that you are <br />not aware that any such gift has been offered, accepted, or promised by any employees of your organization. <br />SIGNATURE OF CONTRACTOR <br />Name of Contractor <br />Trading and doing business as <br />Full name of Firm <br />Address as Prequalified <br />Signature of Witness <br />Signature of Contractor, Individually <br />Print or type Signer's name Print or type Signer's name <br />AFFIDAVIT MUST BE NOTARIZED <br />Subscribed and sworn to before me this the NOTARY SEAL <br />day of_ <br />Individual name <br />20_ <br />Signahae of Notary Public <br />of County <br />State of <br />My Commission Expires: <br />