Tgb & Veteran-Owned Business Description Of Work (Exhibit A) And Field Monitoring Report Form
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2TGB and Veteran
Special Provisions
11/2012
TGB & Veteran-Owned Business Description of Work (Exhibit A)
and Field Monitoring Report
A contract will not be awarded to the Prime Contractor unless this form is submitted for each TGB and Veteran-owned business
participating in the contract. This form is complete when the TGB or Veteran-owned business subcontractor has filled in all of
the applicable information in sections A and B, and signs in section C. PLEASE PRINT CLEARLY OR TYPE.
Section (A): (All TGB & Veteran-Owned Subcontractors and Suppliers, including Trucking firms must complete this Section.)
MUST BE COMPLETED BY THE PRINCIPAL
Check One:
TGB
or
Veteran-Owned Business
Letting Date: ____________________________________
State Project Number: _____________________
Prime Contractor:
Phone #:
TGB/Veteran Subcontractor:
Phone #:
TGB/Veteran Principal Name:
Total Subcontract $: _
TGB/Veteran Participation Claimed: Percent _________%
Amount ________________________
1.
Did you bid and sign a subcontract agreement with the above-named prime contractor? _____________________________
2.
Are the items, quantities, and prices listed on the subcontract agreement or affidavit correct?__________________________
3.
List the line items to be performed: _______________________________________________________________________
________________________________________________________________________________________________________
4.
Are there any other agreements not addressed in the subcontract? If yes, please explain:_____________________________
________________________________________________________________________________________________________
5.
If equipment to be used on this contract is not owned by the TGB/Veteran-owned business, please provide the following
information:
a.
Will the renting or leasing include any of the following: (Attach a copy of the lease/rental agreement(s)).
Equipment __________ Insurance ___________ Operator ___________ or Maintenance ___________
b.
Lessor’s name: __________________________________________________________________________________
Amount to be paid: _____________________ Number of days to be used: ____________________
6.
Will there be any other firm(s) providing work listed in your subcontract?
If yes, answer the following: Firm’s Name: ___________________________ $ amount of the work: __________________
7.
What is the name of the person supervising your work on this project? ___________________________________________
Is this your employee? ____________________
8.
How many people will you be employing on this project? ____________ Minorities: ____________ Females: ___________
9.
Total dollar amount of materials to be supplied? ____________________________________________________________
10. Who are you purchasing the materials from? _______________________________________________________________
11. Please submit Purchase Agreement and/or Purchase Order from manufacturer(s) or primary material supplier(s).
NOTE: This Exhibit ‘A’ will not be approved without the Purchase Agreement/Purchase Order.
12. Please list all subcontracts that your firm will be performing during the current construction season including contracts that
are not in the TGB or Veteran-owned Business Programs (attach additional sheet if necessary)
Project Number
Prime Contractor
Project Location
# of Working Days
1.
2.
3.
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