158698Forms.pdf

VA STATE CORPORATION COMMISSION FORM

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

IFB#:

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):

ATTACHMENT A

IFB# __________________

ATTACHMENT B

NORMAL AND EMERGENCY CONTACTS

Send Contracts To:

Bidder's Name/Title Primary Phone Number:

Bidder's Mailing Address: 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

Contact Person’s Name

Cellular Telephone Number

Telephone Number - Normal Work Hours

Telephone Number – After Work Hours

Fax Number

E-mail Address michele.thompson Cross-Out

Administrative Services/Procurement

IFB #:

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):

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 michele.thompson Typewritten Text

ATTACHMENT C

michele.thompson Typewritten Text

ADDRESS:

SHIPPING POINT:

Attachment D

IFB #:___________________

NAME OF VDOT APPROVED CORRUGATED METAL PIPE PRODUCER AND SHIPPING

POINT: Each bidder shall supply in the space below the name and address of the pipe producer of each item offered and the shipping point.

PIPE PRODUCER: ____________________________________________________________

HENRY COUNTY

1. Carlisle Area Headquarters

55 Jones Ridge Road Axton, VA 24054

ATTACHMENT E

VDOT DELIVERY ADDRESSES

Contact: Chris Clark – 276-650-2238

2. Horsepasture Area Headquarters 18151 A.L. Philpot HWY Ridgeway, VA 24148 Contact: Brandon Boothe – 276-957-1023

3. Martinsville Area Headquarters

399 Weeping Willow Lane Bassett, VA 24055 Contact: David Hutchens – 276-629-2518

PATRICK COUNTY

1. Vesta Sub – Area Headquarters

399 State Shed Road Vesta, VA 24177 Contract: Randy Dalton – 276-930-2241

2. Fairystone Area Headquarters

483 Fairsystone Park HWY Stuart, VA 24171 Contract: Randy Dalton – 276-930-2241

3. Peters Creek Area Headquarters

38 Peters Creek Drive

Contact: Doyle Eaton – 276-694-4193

4. Patrick Springs Area Headquarters

49 Shelton Farm Road

Contact: Doyle Eaton – 276-694-3412

CARROLL COUNTY

1. Fancy Gap Area Headquarters

150 State Shed Road Fancy Gap, VA 24328 Contact: Jordan Lamb – 276-728-2291

2. Laurel Area Headquarters

4171 Airport Road Hillsville, VA 24343 Contact: Scott Hill – 276-728-2114

3. Hillsville Area Headquarters

239 Virginia Street Hillsville, VA 24343 Contact: Paul Chappell – 276-728-7063

ATTACHMENT F