Attachment C-Qualifications~9.pdf
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- Solicitation number
- 25-422DNR-DIREC-B-45052
- Issued by
- Kankakee County, Illinois
About this file
This document is an Attachment C-Qualifications form for a Plugging and Restoration Program Prequalification. The form requires vendors to provide information about their company, including ownership, equipment, and relevant experience. Vendors must describe any outstanding Department of Transportation violations, list their owned or leased plugging and restoration equipment, and summarize their experience with three recent plugging and restoration projects. The form must be completed and signed by an authorized representative of the vendor.
The information provided in this form will be used to prequalify vendors for the Plugging and Restoration Program. Qualified vendors will be eligible to participate in future contract opportunities related to plugging and restoring wells. The form does not provide details about specific contract opportunities, but rather establishes the vendor's qualifications to be considered for such work.
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Text version
Attachment C-Qualifications
Vendor Name:
Home Office Address:
PLUGGING AND RESTORATION PROGRAM PREQUALIFICATION FORM
City
State Zip Code County
Federal Employer Identification Number:
Secretary of State LLC/Corporation File Number:
Please Identify Principal Owners and Officers:
Are you incorporated?
Yes No If yes, in which state?
If incorporated in another State, are you currently authorized to do business in Illinois?
Yes No
*Please type in the following fields. If unable to type on this page, attach a separate typed sheet answering the corresponding fields.
I. If there is a Director's Decision of the Department currently outstanding against you, describe the violations and the date on which they shall be abated:
Citation/ Violation Date: Description
Shall be abated Date:
E-Mail:
Fax:
Name:
Name:
Name:
Name:
Title:
Title:
Title:
Title:
Telephone
Contact Person:
II. Please list all owned plugging and restoration equipment. State any arrangements to obtain necessary equipment that you do not own. Attach extra sheet if necessary.
Own or Lease
Year
Make
Model
Body Style
Description
III. Please provide a summary of your plugging and restoration experience as well as a description of the three most recent plugging and restoration projects and the names and addresses of the persons or entities for whom you have performed such work. Attach extra sheet if necessary
1. Work performed for:
Name
Date
Summary of work Performed:
Address City
Well
Zip State
2. Work performed for:
3. Work performed for:
Person completing this form Date
Signature (must be authorized to enter into contracts on behalf of vendor.)
File details come from the government source that posted it. Updated .