Small Works Roster Application

SUBJECTS › PUBLIC WORKS › Small Works Roster Application

Company______________________________________________

Mailing Address:

______________________________________________________

Street Address (If different):

______________________________________________________

Telephone Number:_______________________________________

FAX Number: ___________________________________________

Email: ___________________________________________________

Banking Reference:

Name of Bank___________________________________________
Address________________________________ Zip_____________

Telephone: ______________________________________________

Type of Ownership: Corporation Single Proprietorship Partnership

Minority and/or Women Owned Businesses: yes no

Business License #: ____________________________________________

Contractors License #: ___________________________________________

Washington State Tax #: _________________________________________

Check boxes that describe types of work your firm qualifies to Perform:

· General Contractor

· Building

· Concrete Placement Finishing

· Electrical

· Heating

· Masonry

· Painting

· Paving

· Road Grading

· Cleaning/Grubbing

· Waterfront or Marina

· Plumbing

· Roofing

· Storm Drainage

· Sewer Systems

· Street Repair and Construction

· Illumination

· Water Systems

· Other_________

Describe experience and qualifications:
________________________________________________________________________

________________________________________________________________________

List 5 references:
1_______________________________________________________________________
2_______________________________________________________________________
3_______________________________________________________________________
4_______________________________________________________________________
5_______________________________________________________________________

Other information regarding your firm's ability to satisfactorily perform a contract:

________________________________________________________________________

By signature below, I acknowledge that I have read and understand the requirements described in this application and to the best of my knowledge the information provided is a true representation of the named firm's ability to perform any contracts which may result by submittal of this application.

___________________________ __________________________________

Typed Name & Title of Preparer Signature

STATE OF WASHINGTON )
) ss.
County of )

On this day personally appeared before me_________________________ known to me to be the individual described in and who executed the within and foregoing instrument,
and acknowledged that _______________________signed the same as his/her free and voluntary act and deed, for the uses and purposes therein mentioned.

Notary Public in and for the State of Washington residing at

__________________________________