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Firm <br />Sign <br />Printed Name David P. Heermance <br />Title President <br />Date 7-30-12 <br />THIS FORM MUST BE COMPLETED AND INCLUDED WITH THE PROPOSAL. <br />PROPOSALS THAT DO NOT CONTAIN THIS FORM WILL BE CONSIDERED NON-RESPONSIVE <br />251-26 <br />national origin, ancestry, physical handicaps, mental condition, marital status, or sex of such persons, <br />except as provided in Section 1420, and any Contractor violating this Section is subject to all the penalties <br />imposed for a violation of the Chapter.