ESBD_544717_1785514924190_Attachment D - Affidavit.pdf
PDF 12 KB Posted
- Attached to
- Prescription/Pharmacy Services
- Solicitation number
- RX1001
- Issued by
- Texas
About this file
This is an affidavit form required for bid submission on a Prescription/Pharmacy Services contract opportunity in Texas. The document mandates that a manager, secretary, or other authorized agent or officer of the bidding firm must appear before a notary public and swear under oath that the bidder is not a member of any trust, pool, or combination formed to control prices or influence bidding activity. The affiant must further attest that the bidder has not given, offered, or intends to give any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to any public servant in connection with the submitted bid.
The affidavit requires completion of bidder identification information including the name, signature, title, address, zip code, telephone number, and date. A notary public licensed in a Texas county must witness the sworn statement and provide their certification with the date of notarization. The document explicitly states that bids not accompanied by this completed and notarized affidavit will not be considered for award, making this affidavit a mandatory submission requirement for all bidders responding to this Prescription/Pharmacy Services opportunity.
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Text version
Attachment D
AFFIDAVIT
BEFORE ME, the undersigned authority, on this day personally appeared __________________________________________ known to me to be the person whose name is subscribed to the following, who upon oath, says:
I AM THE Manager, Secretary or other agent or officer or the principal of the Bidder in the matter of the bids to which this affidavit is attached, and I have full knowledge of the relations of the Bidder with the other firms in this same line of business, and the Bidder is not a member of any trust, pool, or combination to control the price of supplies bid on, or to influence any person to bid or not bid thereon.
I further affirm that the Bidder has not given, offered to give, nor intends to give at any time hereafter any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant in connection with the submitted bid.
Affiant
SWORN TO AND SUBSCRIBED BEFORE ME by the above Affiant, who, on oath states that the facts contained in the above are true and correct this _______________________day of __________________, 20___.
Notary Public in and for
__________________________________ County, Texas
Name of Bidder: ______________________________________________
Signed by: ______________________________________________
(Sign Name in Writing) (Title)
Address: ______________________________________________ (Zip Code)
Telephone Number: ______________________________________________
(Date)
NOTE: BIDS NOT ACCOMPANIED BY THIS AFFIDAVIT WILL NOT BE
CONSIDERED.
File details come from the government source that posted it. Updated .