Certification Of Responsible Contractor Status printable pdf download

Certification Of Responsible Contractor Status

APPENDIX A

Responsible Contractor Program Policy

CERTIFICATION OF RESPONSIBLE CONTRACTOR STATUS

GENERAL INFORMATION

Company Name

Address

City

State

Zip Code

Telephone Number (

)

Fax Number (

)

Ownership Structure (Please check one)

 Sole Proprietorship  Partnership  Corporation  Joint Venture  Other_________

Description of Service(s) Provided

Contractor’s License #

RESPONSIBLE CONTRACTOR STATUS

(Refer to definitions and worksheet on pages 3 and 4 of this Appendix)

Please check one of the following boxes:

 Meets all Responsible Contractor requirements

 Meets none of the Responsible Contractor requirements

 Meets certain of the Responsible Contractor requirements (provide explanation below)

If you have checked box 3 above, please provide an explanation below. (Attach additional pages

if necessary.)

Explanation:___________________________________________________________________

______________________________________________________________________________

___________________________________

Certification Of Responsible Contractor Status