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DocuSign Envelope ID: 131 D50716-7603-4905-88E6-3348AF487601 <br /> RESPONDER'S CERTIFICATION FORM <br /> I have carefully examined the Request for Qualifications, the sample Agreement for Design <br /> Consultant Services and any other documents accompanying or made a part of this Request for <br /> Qualification. <br /> hereby propose to furnish the professional design consultant services for Orange County in <br /> accordance with the instructions, terms, conditions, and requirements incorporated in this Request for <br /> Qualification. I certify that all information contained in this response is truthful to the best of my <br /> knowledge and belief. l further certify that I am duly authorized to submit this response on behalf of <br /> the firm as its act and deed and that the firm is ready, willing and able to perform if awarded the <br /> contract. <br /> NAME OF FIRM: summit Design and Engineering Services,PLLC <br /> BY: (printed name) Edmund W.Purcell,PLS <br /> SIGNATURE: <br /> MAILING ADDRESS: 504 Meadowland Drive <br /> CITYISTATElZIP CODE Hillsborough,NC 27278 <br /> TELEPHONE NUMBER: . 919-732-3883 <br /> FAX NUMBER' 919-732-6676 <br /> ACKNOWLEDGEMENT OF ADDENDA <br /> Responder hereby acknowledges receipt of all Addenda through and including: <br /> Addendum No. Date Acknowledgement <br /> 1 10/5/2015 X <br />