T0170 Subcontractor Utilization Form.pdf

STATE OF NEW JERSEY

DEPARTMENT OF THE TREASURY

DIVISION OF PURCHASE AND PROPERTY

33 WEST STATE STREET, P.O. BOX 230

TRENTON, NEW JERSEY 08625-0230

SUBCONTRACTOR UTILIZATION FORM*

List All Businesses To Be Used As Subcontractors. Attach Additional Sheets If Necessary

BID SOLICITATION #:

BID SOLICITATION TITLE:

VENDOR’S NAME:

ADDRESS:

PHONE NUMBER:

EMAIL:

FEIN:

SUBCONTRACTOR’S NAME:

ADDRESS:

PHONE NUMBER:

EMAIL:

ESTIMATED VALUE OF WORK TO BE SUBCONTRACTED:

DESCRIPTION OF WORK TO

BE SUBCONTRACTED:

IS THE SUBCONTRACTOR A SMALL BUSINESS? IS THE SUBCONTRACTOR A DISABLED VETERAN-

OWNED BUSINESS?

YES NO YES NO

IF YES, SMALL BUSINESS CATEGORY:

I II III IV V VI

FEIN:

SUBCONTRACTOR’S NAME:

ADDRESS:

PHONE NUMBER:

EMAIL:

ESTIMATED VALUE OF WORK TO BE SUBCONTRACTED:

DESCRIPTION OF WORK TO

BE SUBCONTRACTED:

IS THE SUBCONTRACTOR A SMALL BUSINESS? IS THE SUBCONTRACTOR A DISABLED VETERAN-

OWNED BUSINESS?

YES NO YES NO

IF YES, SMALL BUSINESS CATEGORY:

I II III IV V VI

FEIN:

SUBCONTRACTOR’S NAME:

ADDRESS:

PHONE NUMBER:

EMAIL:

ESTIMATED VALUE OF WORK TO BE SUBCONTRACTED:

DESCRIPTION OF WORK TO

BE SUBCONTRACTED:

IS THE SUBCONTRACTOR A SMALL BUSINESS? IS THE SUBCONTRACTOR A DISABLED VETERAN-

OWNED BUSINESS?

YES NO YES NO

IF YES, SMALL BUSINESS CATEGORY:

I II III IV V VI

* If the Bid Solicitation has subcontracting set-aside goals, and the Vendor has not achieved the goals, Vendor must attach information documenting its good faith effort to achieve the goals. DPP Rev. 3.14.19