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a <br />CITY OF SANTA ANA <br />ATTACHMENT D <br />NON -COLLUSION AFFIDAVIT <br />(Title 23 United States Code Section 112 and Public Contract Code Section 7106) <br />To the CITY OF SANTA ANA <br />In accordance with Title 23 United States Code Section 112 and Public Contract Code 7106 the proposer <br />declares that the proposal is not made in the interest of, or on behalf of, any undisclosed person, <br />partnership, company, association, organization, or corporation; that the proposal is genuine and not <br />collusive or sham; that the proposer has not directly or indirectly induced or solicited any other proposer <br />to put in a false or sham proposal, and has not directly or indirectly colluded, conspired, connived or <br />agreed with any proposer or anyone else to put in a sham proposal, or that anyone shall refrain from <br />bidding; that the proposer has not in any manner, directly or indirectly, sought by agreement, <br />communication, or conference with anyone to fix the proposal price of the proposer or any proposer, or <br />to fix any overhead, profit, or cost element of the proposal price, or of that of any other proposer, or to <br />secure any advantage against the public body awarding the contract of anyone interested in the <br />proposed contract; that all statements contained in the proposal are true; and, further, that the proposer <br />has not, directly or indirectly, submitted his or her proposal price or any breakdown thereof, or the <br />contents thereof, or divulged information or data relative thereto, or paid, and will not pay, any fee to any <br />corporation, partnership, company association, organization, bid depository, or to any member or agent <br />thereof to effectuate a collusive or sham proposal. <br />Note: The above non -collusion affidavit is part of the proposal. Signing this proposal on the signature <br />portion thereof shall also constitute signature of this non -collusion affidavit. Proposers are cautioned that <br />making a false certification may subject the certifier to criminal prosecution. <br />Signed <br />State of , County of <br />Subscribed and sworn to (or affirmed) before me on this day of , 20 , by <br />, proved to me on the basis of satisfactory evidence to be the person(s) <br />who appeared before me. <br />Notary Public Signature Notary Public Seal <br />THIS FORM MUST BE COMPLETED AND INCLUDED WITH THE PROPOSAL. <br />PROPOSALS THAT DO NOT CONTAIN THIS FORM WILL BE CONSIDERED NONRESPONSIVE. <br />23-115 Pre -Employment Medical Screening Services Page 31 of 34 <br />