36C26118B0377-023.docx
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- 612-18-2-6056-0028 | #612A4-18-233 | VA261-18-AP-4727 | Consolidated Chilled Water and Heating Piping B-650
- Solicitation number
- 36C26118B0377
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36C26118B0377 CONTRACTOR CERTIFICATION REGARDING SAFETY AND ENVIRONMENTAL.docx
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CONTRACTOR CERTIFICATION REGARDING SAFETY AND ENVIRONMENTAL
Contractor Certification Regarding Project: 612A4-18-233
| 2015 |
| 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 disqualifies the contractor.)
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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