158661 Attachments.pdf

Administrative Services/Procurement

Bristol District/

IFB #

ATTACHMENT

STATE CORPORATION COMMISSION FORM

Failure to complete and return this attachment may result in your bid being deemed NON-RESPONSIVE.

Virginia State Corporation Commission (SCC) registration information. The bidder: _____________________________ is a corporation or other business entity with the following SCC identification number: ___________________ -OR-is not a corporation, limited liability company, limited partnership, registered limited liability partnership, or business trust

-OR-

is an out-of-state business entity that does not regularly and continuously maintain as part of its ordinary and customary business any employees, agents, offices, facilities, or inventories in Virginia (not counting any employees or agents in Virginia who merely solicit orders that require acceptance outside Virginia before they become contracts, and not counting any incidental presence of the bidder in Virginia that is needed in order to assemble, maintain, and repair goods in accordance with the contracts by which such goods were sold and shipped into Virginia from bidder’s out-of-state location) -OR-is an out-of-state business entity that is including with this bid an opinion of legal counsel which accurately and completely discloses the undersigned bidder’s current contacts with Virginia and describes why those contacts do not constitute the transaction of business in Virginia within the meaning of § 13.1-757 or other similar provisions in Titles 13.1 or 50 of the Code of Virginia.

**NOTE** >> Check the following box if you have not completed any of the foregoing options but currently have pending before the SCC an application for authority to transact business in the Commonwealth of Virginia and wish to be considered for a waiver to allow you to submit the SCC identification number after the due date for bids (the Commonwealth reserves the right to determine in its sole discretion whether to allow such waiver):

IFB

ATTACHMENT

NORMAL AND EMERGENCY CONTACTS

Send Contracts To:

Bidder's Name/Title Primary Phone

Number

Bidder's

E-mail

Address:

Bidder’s Mailing

Address:

Contact Person’s Name

Cellular Telephone Number

Telephone Number - Normal

Work Hours

Telephone Number - After

Work Hours

Fax Number

E-mail Address

Contact Person’s Name

Cellular Telephone Number

Telephone Number - Normal

Work Hours

Telephone Number - After

Work Hours

Fax Number

E-mail Address

Contact Person’s Name

Cellular Telephone Number

Telephone Number - Normal

Work Hours

Telephone Number - After

Work Hours

Fax Number

E-mail Address

Set-Aside for Small Business

IFB #

ATTACHMENT

SUBCONTRACTOR APPROVAL REQUEST

No portion of the work (including equipment) shall be subcontracted to another firm or individual without prior written consent of Virginia Department of Transportation (herein referred to as VDOT). In the event that the Contractor desires to subcontract some part of the work specified herein, the Contractor shall furnish VDOT with the names, qualifications, and experience of their proposed subcontractors for agency approval. The primary Contractor shall, however, remain fully liable and responsible for the work performed by its subcontractor(s) and shall assure compliance with all requirements of the contract.

List proposed subcontractor(s), including name, address, contact person, and type of work to be performed under this contract below.

FIRM INDIVIDUAL’S

NAME & ADDRESS

CONTACT PERSON AND

PHONE NUMBER

TYPE OF WORK TO BE PERFORMED

TYPE OF EQUIPMENT PROPOSED SUBCONTRACTOR WILL PROVIDE

QUALIFICATIONS / EXPERIENCE LEVEL OF PROPOSED SUBCONTRACTOR

Please indicate which above proposed subcontractors are certified (with DSBSD) as Small, Women Owned or Minority Businesses.

Certification

Number(s):

Cer Certificat

FOR VDOT USE ONLY:

The proposed subcontractor(s) listed above is/are approved and accepted under the terms and conditions of the contract requirements herein.

Signature of Authorized VDOT

Representative

Date Telephone Number