7-04 Contractors Qualification Statement.pdf

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4. CONTRACTOR’S QUALIFICATION STATEMENT

Note: Attach separate sheets as required.

The undersigned certified the truth and correctness of all statements and of all answers to questions made hereinafter.

TO: Northampton Township 55 Township Road Richboro, PA 18954

Submitted by: Corporation

Name: Partnership

Address: Individual

Principal Office: Joint Venture

Other

How many years has your organization been in business as a Contractor?

How many years has your organization been in business under its present business name?

If a corporation, answer the following:

1) Date of incorporation:

2) State of incorporation:

3) President’s name:

4) Vice President’s name(s):

5) Secretary or Clerk’s name:

6) Treasurer’s name:

7) List name and address of all parties holding greater than ten percent (10%) interest in the corporation:

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If individual or partnership, answer the following:

1) Date of origination:

2) Name and address of all partners (State whether general or limited partnership):

If other than corporation or partnership, describe organization and name principals:

List and provide the number of accidents/insurance claims your organization has had related to hauling services over the past three (3) years.

List five (5) past clients and/or municipalities in which your organization has provided hauling related services to in the past and provide a contact number for each.

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Dated at this day of , 20 .

Name of Organization:

By:

Title:

M , being duly sworn, deposes and says that he/she is the of Contractor(s), and that answers to the foregoing questions and all statements therein contained are true and correct.

Subscribed and sworn before me this day of , 20 .

Notary Public:

My Commission Expires: