PURCHASING DEPARTMENT - JacksonGov.org

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Jackson County Missouri Invitation to Bid No. 2-08 Page 6 of 22 STATEMENT OF CONTRACTOR'S QUALIFICATIONS - Continued Has Contractor ever been sued for breach of any contract? Yes No (Check one) If Yes, Explain: List Completed Contracts within the Past Three Years, Including Amount of Each: List of Current Contracts, Including Amount of Each: Customer Reference (state name, address, and phone number): List each subcontractor you plan to use if awarded the contract. If no, so state. SUBCONTRACTOR'S NAME & PHONE # ITEM OF WORK $ AMOUNT OF CONTRACT MBE/WBE State any other relevant information concerning Contractor's history, credentials, responsibility and capabilities (If none, so state): DBE STATUS Indicate status claimed: 1. Minority Owned Business (MBE) YES____ NO____ African American____ Latino____ Native American____ Asian____ Pacific Islander____ 2. Woman Owned Business (WBE) YES____ NO____ 3. Small Business YES____ NO____ For consideration as an MBE, WBE or Small Business, a copy of any governmental entity or Minority Supplier Council certification must be attached. Prepared by (print or type): Signature: Title: Date:
Jackson County Missouri Invitation to Bid No. 2-08 Page 7 of 22 ACKNOWLEDGMENT OF RECEIPT OF ADDENDA The undersigned acknowledges receipt of Addenda through and including numbers________________ and that this Proposal is submitted in accordance with information, instructions, and stipulations set forth therein. _________________________________________________________________ Signature of Respondent _______________ Date ___________________________________________________________________ Company Name ___________________________________________________________________ Address ___________________________________________________________________ City, State, and Zip _________________ Phone
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PURCHASING DEPARTMENT - JacksonGov.org

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