N.C. WX Assistance Program

Subcontractor Profile

Page 2

NORTH CAROLINA WEATHERIZAITON ASSISTANCE PROGRAM

SUBCONTRACTOR PROFILE & CERTIFCATION

1.  Subgrantee Name:

2.  Telephone: Fax:

3.  Contract Period:

Subcontractor Information

4.  Business Name:

5.  Owner(s) Name:

6.  Address:

7.  Telephone: Fax:

8.  Email address:

9.  Company Structure (corporation, partnership, sole proprietorship):

10. Business Type:

11. Years in Business:

12. Federal Tax Identification Number:

13. Type of Work to be Performed (list all types to be performed in specific terms of N.C. Priority Lists):

Blower door directed air sealing

Attic insulation Sidewall insulation

Floor insulation Duct sealing and insulation

Water heater and pipe insulation _____Other:

General heat waste (weather-stripping, aerators, etc.)

14. Years of Weatherization Work Experience (if none, list similar, related experience):

15. Identify equipment owned by subcontractor that will be used in performing weatherization work (measures listed on N.C. Priority List of Measures for Single Family and Mobile Homes):

Equipment /

Manufacturer

/

Model

/ Year Purchased / Condition
Blower Door
Insulation Machine
Generator
Combustion Analyzer

Previous WX Training Received by Subcontractor and Staff (all persons that will perform weatherization work must be listed)

Individual Name Course Name Dates Trainer

16. Attach a copy of licenses (include professional, state and or local business or privilege licenses).

17. Attach a copy of the invoice to be used by the subcontractor.

Subgrantee Subcontractor Certification

As chief executive officer of the above named organization, I certify that competitive procurement procedures outlined in 10CFR600 and the procurement policies and procedures of our organization were followed in the procurement of the subcontractor identified above and further that after review of the business credentials, liability, workmen’s compensation and pollution occurrence Insurance coverage held by the subcontractor and to the best of my knowledge the subcontractor identified herein possesses the skills; knowledge; experience; abilities; tools and equipment and appropriate state and local business licenses and credentials to perform the weatherization work identified in item 12 above in accordance with the N.C. Weatherization Program Installation Standards and the N.C. Weatherization Priority List of Measures for Single Family and Mobile Homes. I certify that my staff has verified that this subcontractor is not listed on Excluded parties List System or the Suspension of Funding List.

______

Typed Name of Executive Director:

______

Signature of Executive Director Date

October 10