Ets Form 121 - Construction Project And General Contractor Registration printable pdf download

Ets Form 121 - Construction Project And General Contractor Registration

Wyoming Department of Revenue

122 West 25

Street

Cheyenne, WY 82002-0110

307-777-5200

Construction Project and General Contractor Registration

(Please note that the general contractor must complete and remit this form to the above address within 15 days of project award date)

Project Information:

1. Project Name:______________________________________________________________________

2. Physical Address of Project:___________________________________________________________

3. Project Owner:______________________________________________________________________

4. Total Project/Contract Amount:$________________________________________________________

5. Anticipated Start Date:_____________________ 6. Anticipated Completion Date:_________________

General Contractor Information:

7. General Contractor:____________________________________FEIN/SS#______________________

8. Mailing Address:____________________________________________________________________

9. City, State, Zip:_____________________________________________________________________

10. Phone Number:____________________(800) Number_________________Fax#:________________

11. Contact Person:_____________________________________________________________________

12. E-Mail Address:_____________________________________________________________________

13. Will there be any non-resident subcontracts? Yes

14. Describe your scope of work:__________________________________________________________

(

remodel, renovation, new construction, house, office bldg. Etc.)

Note: You must enclose a copy of the bid contract that describes the scope of work you were hired to

perform.

We have been contracted by_________________________________to be the General Contractor for the

project identified above.

(Real Property Owner)

We estimate the cost of our materials for this project will be:$__________________________________

I declare, under penalty of perjury, the information provided above is correct and complete .

Authorized Signature:________________________________ Title:__________________________________________

Printed Name:______________________________________

________________________________________

___________________________________________

Date

FEIN/SS#

(This form may be duplicated as necessary)

ETS Form 121 (Revised 07/15/02)

Ets Form 121 - Construction Project And General Contractor Registration