smallworksroster

Small Works Roster Form

Statement of Qualifications

Company Name *

Unified Business Identifier / WA State Tax registration No. *

Owner Name *

Site Address *

Mailing Address *

Mailing City State and Zip *

Phone Number (Incude Area Code xxx-xxx-xxxx) *

Mobile Number

Fax Number

E-Mail *

After Hours No. (Emergency Contact)

WA Contractor's License? Yes No

WA Contractor's License Number

If No Contractor's License, Business License Number

Expiration Date

WA Labor & Industries Workers' Comp Number

WA Employment Security Number

Federal Employment Tax ID Number

Electrical Contractors Licence Number. (If Applicable)

Firm must hold an active WA State Department of Revenue Account *

The contractor shall certify that they are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participating in covered transactions by any State or Federal department or agency. *

Insurance Company *

Insurance Agent Name

Insurance Address

Insurance Phone Number

NOTE, Contractor must be able to provide as a minimum, the following insurance policy:

Automobile liability of $1,000,000 covering all owned, non-owned, hired, and leased vehicles; commecial general liability of $1,000,000 single limit and $2,000,000 agregate; and, if applicable, professional liability insurance of $1,000,000

Company must submit a copy of their certificate of liability insurance to qualify for the City of Camas Small Works Roster

Certificate of Liability Insurance (Word or PDF Only, Please limit size to 5MB)

Bonding Company (Required if Licensed Contractor)

Bonding Agent Name

Bonding Address

Bonding Phone Number

Bonding Capacity

Small or Disavanteged Business Certification (DBE)

DBE Business Status

DBE Business Status Certification Number

Attach DBE Business Status Document (Word or PDF Only, Please limit size to 5MB)

If you can not attach your DBE certification document now select your intent

Per City of Camas Ordinance No. 2626, as a condition for the award or renewal of any contract after January 1, 2012, the Contractor shall enroll in the E-Verify program through the United States Department of Homeland Security and thereafter shall provide the City a copy of the Memorandum of Understanding (issued by Homeland Security), submitted with their bid proposal, affirming their enrollment and participation in the program. The Contractor shall be required to continue their participation in the program throughout the course of their contract with the City. Prime contractors shall require and verify that each of their subcontractors and lower tiered subcontractors are also enrolled and participants in the E-Verify program. This is intended to be used exclusively for employees hired after award and for the duration of the contract with the City of Camas. Please go to the Engineering page of the City of Camas web site at www.cityofcamas.us for additional information and to view Ordinance No. 2626.

E-Verify, is an Internet based system operated by the Department of Homeland Security in partnership with the Social Security Administration at no charge. E-Verify has been determined to be a suitable means for determining employment eligibility of new hires and the validity of their Social Security numbers. Please visit the Department of Homeland Security's web site at http://www.dhs.gov and select E-Verify to learn more or to enroll in this program.

Is your company enrolled in E-Verify? Yes No

I have read the E-Verify information and understand that the City of Camas will not enter into a contract without confirmation of enrollment and participation in the E-Verify program. *

As provided by Title VI of the Civil Rights Act of 1964, and the Civil Rights Restoration Act of 1987, the contractor, with regard to the work performed by it during the contract, shall not discriminate on the grounds of race, color, religion, sex or national origin in the selection and retention of sub-contractors, including procurement of materials and leases of equipment.

Thank You for submitting the Small Works Roster Form. You will get a confirmation E-Mail shortly. Please contact Ronda Syverson rsyverson@cityofcamas.us if you have any further questions about the process.