Small Works Roster Application - 2018

If you wish to be placed on the Town of Concrete Small Works Roster, all sections of the following application must be completed, if applicable and returned to the Town of Concrete. Applications are valid for one (1) calendar year.

The Town of Concrete is an equal opportunity provider and employer, we encourage Minority and Women-Owned and Disadvantaged businesses to compete for Town of Concrete public contracts and services. Prior to contracting the Town may require additional information such as references, statement of qualifications, insurance requirements, performance bond, etc.

Notices of projects that meet Small Works Roster requirements will be sent to those qualified vendors/contractors by U.S. Mail but will also be sent by email if provided.

PLEASE COMPLETE

Name of Applicant or Firm (As registered with Washington State Department of Licensing)
Contact Name / Contact Title
Street Address / City / State / Zip Code
P.O. Box / City / State / Zip Code
Telephone / Fax / Email:
Type of Ownership:  Corporation  Sole Proprietorship  LLC  Other ______
The above Applicant or Firm’s Certification Status:
 MBE – Minority Business Enterprise
 WBE – Women Business Enterprise
 DBE – Disadvantaged Business Enterprise / Federal Tax Identification No.
State of Washington UBI No.
State of Washington Contractor Registration No.
Town of Concrete Business License  NO  YES #______

Complete Next Page

Appraisers /  Asphalt Paving and Concrete /  Carpet Installation
Building /  Concrete Placement/Finishing /  Environmental
General Contractor /  Painting /  Road Grading
Waterfront /  Roofing /  Illuminations
Water Systems /  Storm Drainage /  Septic Systems
Sewer Systems /  Road/Street Repair /  Electrical
Road/Street Construction /  Heating/Cooling /  Masonry
Plumbing /  Asbestos Abatement /  Demolition
Lead Abatement /  Fencing /  Surveyor
 Other ______
 Other ______
 Other ______

Services Provided (Check All That Apply):

By completing and signing this form, the firm or company acknowledges they have read and understand the requirements described in this application and to the best of their knowledge, information provided is a true representation of the named firm’s ability to perform any contracts which may result by submittal of this application and said firm or company is licensed and registered to perform work in Washington State.

Applications to be listed on the Town of Concrete’s Small Works Roster are a certification by the contractor and their subcontractors that they will pay prevailing wage on all contracts awarded by the Town and will comply with any local, state or federal contract laws as they pertain to a particular project.

Prepared By:

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SignatureDate

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Printed NameTitle

>Applications Must Be Submitted Every Year to Remain on the Small Works Roster<

Please submit applications by mail at P.O. Box 39, Concrete, WA 98237, fax to 360.853.8002, email to or hand deliver to 45672 Main Street.