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Submittal of Non-Collusion Affidavit and Debarment Certification prior to bidding <br /> Submit to the Prequalification Office Rev.2-1-10 <br /> NON-COLLUSION AFFIDAVIT,DEBARMENT CERTIFICATION AND GIFT BAN CERTIFICATION <br /> CORPORATION f <br /> The prequalified bidder being duly sworn, solemnly swears(or affirms) that neither he,nor any official, agent or <br /> employee has entered into any agreement,participated in any collusion, or otherwise taken any action which is in <br /> ' restraint of free competitive bidding in connection with any bid or contract,and that the prequalified bidder intends <br /> to do the work with his own bonafide employees or subcontractors and will not bid for the benefit of another <br /> contractor. <br /> ' By submitting this non-collusion affidavit,the Contractor is certifying his status under penalty of perjury under the <br /> 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 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 PREQUALIFIED BIDDER <br /> i <br /> Full name of Corporation <br /> Address as Prequalified <br /> i <br /> Attest Zr_/,/ By <br /> Secretary/Assis� tsry Pre ' en t <br /> Select appropriate title Select appropriate title <br /> ' f Print or type Signer's name Print or type Signer's name <br /> CORPORATE SEAL <br /> AFFIDAVIT MUST BE NOTARIZED <br /> Subscribed and sworn to before me this the <br /> p� day of 20YY <br /> Si ature of Notary Public <br /> Of County NOTARjI SEAL <br /> ' State of <br /> My Commission Expires: of w <br /> i <br />