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KITTITAS COUNTY BID PROPOSAL <br /> <br />Liquid Asphalt Material Bid 2022 Page 13 of 14 <br /> <br />BIDDER QUALIFICATION STATEMENT <br /> <br /> <br />NAME OF FIRM: <br /> <br /> <br />ADDRESS: <br /> <br /> <br /> <br /> <br /> <br />TELEPHONE: FAX: <br /> <br />FEDERAL I.D. TAX NO. <br /> <br />TITLE & NAME OF PERSON PREPARING BID: <br /> <br /> <br />NON-COLLUSION DECLARATION <br /> <br />I, by signing the proposal, hereby declare, under penalty of perjury under the laws of the <br />United States that the following statements are true and correct: <br /> <br />1. That the undersigned person(s), firm, association or corporation has (have) not, <br />either directly or indirectly, entered into any agreement, participated in any collusion, <br />or otherwise taken any action in restrain of free competitive bidding in connection <br />with the project for which this proposal is submitted. <br /> <br />That by signing the signature page of this proposal, I am deemed to have signed and <br />have agreed to the provisions of this declaration. <br /> <br /> <br />ADDITIONAL ASSURANCE AND CERTIFICATIONS <br />Bidder hereby certifies that he/she will comply with all assurances and certifications <br />issued by Kittitas County, and conform to all applicable state and federal laws. <br /> <br />The bidder is hereby advised that by signature of this proposal he/she is deemed to <br />have acknowledged all requirements and signed all certificates contained herein. <br /> <br /> <br /> ____________________________________________________ <br /> FIRM NAME <br /> <br /> ____________________________________________________ <br /> Signature of Authorized Official <br /> <br />Type Name: _________________________________________ <br /> <br />Title: _______________________________________________ <br />