2. NAME OF DEPARTMENT:
4. Due Date:
5. Time Due:
Proposals should be sent by the following method:
7. MAIL OR FAX PROPOSALS TO:
The bottom portion of this form is to be completed by the vendor.
Equal Employment Opportunity – All parties must be in compliance with executive order 11246 of September 24, 1965 as amended by
executive order 11375 of October 13, 1967.
STATEMENT OF NON-COLLUSION AND NON-CONFLICT OF INTEREST
I hereby swear (or affirm) under penalty for false swearing as provided by:
That attached Request For Proposal has been submitted without collusion with, and without any agreement, understanding or planned
common course of action with, any other vendor of materials, supplies, equipment or services described in the Request For Quotation
designed to limit independent competition.
That the proposer is legally entitled to enter into the contract with the _____________________________, and is not in violation of
any prohibited conflict of interest, including those prohibited by the provisions of State law.
That I have fully informed myself regarding the accuracy of the statements made above.
In submitting this quotation, it is expressly agreed that upon proper acceptance by ______________________, of any or all items bid, a
contract shall thereby be created with respect to the services accepted.