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

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1616 Contract No. ~~, ORANGE rev. ~-lz-io EXECUTION OF BID NON-COLLUSION AFFIDAVIT, DEBARMENT CERTIFICATION AND GIFT BAN CERTIFICATION INDIVIDUAL DOING BUSINESS IN ffiS OWN NAME The person executing the bid, on behalf of the Bidder, being duly sworn, solemnly swears (or affirms) that neither he, nor any official, agent or employee of the bidder 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 any bid or contract, that the bidder has not been convicted of violating N.C.G_S. § 133-24 within the last three years, and that the Bidder intends 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 maffier also constitutes the Biddet'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 exc~tions that are applicable. N.C.G.S. § 133-32 and Executive Order 24 prohibit the offer to, or acceptance by, any State EmQloyee of any gift 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 aze not aware that any such gift has been offered, accepted, or promised by any employees of your organisation. SIGNATURE OF CONTRACTOR Name of Contractor Print or type Individual name Address as Prequalified Signature of Contractor, Individually Print or type Signer's Name Signature of witness Print or type Signer's name AFFIDAVIT MUST BE NOTARIZED Subscribed and sworn to before. me this the NOTARY SEAL day of 20 Signature of Notary Public of State of .County My Commission Expires: