36C25019B0055-006.docx

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Upgrade Building Management System, Marion (VA-19-00074140)
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36C25019B0055
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36C25019B0055 Contractor Certification Regarding Safety and Environmental.docx

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Contractor Certification Regarding Project: 610-18-105

2016
2017
2018

Number of serious, willful, or repeat violations from OSHA within the last 3 years. Please attach explanation for any violations. (Four serious, one repeat, or one willful violation could result in being determined non-responsible.)

Company’s Current Insurance Experience Modification Rate (EMR) = _____________ (Note: Contractor must support the EMR with a signed letter from Insurance Carrier on their letterhead.)

Signature: ______________________________________________

Typed Name: ______________________________________________________

Title: ______________________________________________________

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