REQUEST FOR OFFICIAL PROPOSAL FORM (R109)
Date: ________________________________
Name of Company:
______
Address:
City:
State:
Zip:
Contact Person:
Phone Number: ____________________________ E-mail Address:_____________________________
Vendor Code: _____________________________
Original Signature, Title and Date
R109 form must be signed by an authorized representative of the company. In accordance with 720 CMR Section 5.04 (2) and under the
penalties and perjury, I certify that the above combination of the project value plus the firm’s uncompleted work does not exceed the firm’s
aggregate bonding capacity. CSD-681 (R109) (REV. 09/18/2012)
MASSDOT Prequalified
DCAM General Bid
DCAM Filed Sub-Bid
*DCAM General and Sub Contractors must submit an electronic copy of their DCAM Certificate of Eligibility
Bid Opening
Project Number
City/Town
Project Description
Date
Project Value
1
2
3
4
5
6
7
8
To request for obtaining bidding documents on Compact Discs free of charge for the following projects
(MASSDOT projects
only). Contractors who wish to have a CD containing plans & specifications shipped to them must provide a completed mailing label
for each project with an approved carrier account number for overnight mail service to the Construction Contracts Cashiers Office,
located in room 6260 or email
MassDOTBidDocuments@dot.state.ma.us
Please email the R109 form to MASSDOT at:
prequal.r109@state.ma.us
or mail this form to:
MASSDOT – Highway Division
Prequalification Department
10 Park Plaza, Room 6260
Boston, MA 02116
Questions? Call (857) 368 - 8660