Form 25d-6 - Bidder'S Registration Form - Alaska Department Of Transportation Civil Rights Office - Dbe Program

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9/6/2000 11:28 am
Alaska Department of Transportation Civil Rights Office – DBE Program
BIDDER’S REGISTRATION FORM
All firms (DBE and non-DBE) bidding on Alaska Department of Transportation and Public
Facilities (ADOT&PF) projects must be registered. Each contractor, subcontractor, or supplier
shall complete this form in typewritten format and fax to: (907) 269-0847 or mail to:
ADOT&PF Civil Rights Office
PO Box 196900
Anchorage, Alaska 99519-6900
If you have any questions, please call (907) 269-0851.
Name of Firm: ________________________________________________________________________
Name of Person filling out form __________________________________________________________
Street Address: ________________________________________________________________________________
Mailing Address: _______________________________________________________________________________
City: _______________________________ State: ____ Mailing Zip Code: ________________________
Telephone No: ____________
Fax No: __________________ *Physical Zip Code ________________
E-mail Address: _________________________________________________________
Date Firm was Established: ___________________
*for firms with PO Box, SRA, Rural Route, etc...
Check all that apply:
Is this firm a prime contractor? Y_____ N_____
Is this firm a subcontractor?
Y_____ N_____
Identify specialty:
_______________
Is this firm a service provider? Y_____ N_____
Identify service:
Is this firm a material supplier? Y_____ N_____
Identify:
_______________
Is this firm a manufacturer?
Y_____ N_____
Identify:
_______________
Is this firm a certified DBE?
Y_____ N_____
If so, by Whom?
___State of Alaska
___Municipality of Anchorage
___other
__________________________
name of organization
Type of contract bid by the firm:
FHWA
FAA
FTA
Firm’s gross annual receipts:
<$500,000
$500,000 - $999,999
$1,000,000 - $4,999,999
Print this page
$5,000,000 - $9,999,999
$10,000,000 - $16,999,999
>$17,000,000
Form 25D-6 (9/1/2000)

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