26-014R WRWWTF Electrical Building Design-Build Entity Reference Form.docx

DESIGN-BUILD ENTITY REFERENCE FORM

WESTERN REGION WASTEWATER TREATMENT FACILITY PHASE 2 ELECTRICAL BUILDING & RESILIENCY IMPROVEMENTS PROGRESSIVE DESIGN-BUILD

PBCWUD PROJECT NO. 26-014R, PACKAGE IDENTIFICATION NO. GL04

PALM BEACH COUNTY, FLORIDA

THE REFERENCE FORM SHALL BE SUBMITTED IN THE FORMAT ATTACHED.

THE DESIGN-BUILD ENTITY MUST COMPLETE THE FOLLOWING INFORMATION AND ANY OTHER INFORMATION OR ATTACHMENTS.

PROPOSER’S INFORMATION

COMPANY NAME:

BUSINESS ADDRESS:

CITY, STATE, ZIP CODE:

TELEPHONE:

FAX:

E-MAIL:

PRINT NAME OF AUTHORIZED REPRESENTATIVE:

TITLE OF AUTHORIZED REPRESENTATIVE:

SIGNATURE OF AUTHORIZED REPRESENTATIVE:

REFERENCE NO. 1 (1)

Reference Name/Title/Corporation Name:

Reference Telephone Number:

Reference E-Mail Address:

Contract Year/Amount:

Project Title:

Project Location:

Description of Project:

(1) Add references as required by the Design-Build Entity Minimum Qualifications document.

REFERENCE NO. 2 (1)

Reference Name/Title/Corporation Name:

Reference Telephone Number:

Reference E-Mail Address:

Contract Year/Amount:

Project Title:

Project Location:

Description of Project:

REFERENCE NO. 3 (1)

Reference Name/Title/Corporation Name:

Reference Telephone Number:

Reference E-Mail Address:

Contract Year/Amount:

Project Title:

Project Location:

Description of Project: