cdbg scattered site housing program
TRANSCRIPT
CDBG Scattered Site Housing Program
Contractor Information Sheet
Name:
Company:
Address:
Contact: Office Phone:
Name of owner, partner or president:
State licenses: (1)
Other licenses: (1)
(2)
(2)
Employer ID #:
Home Phone:
E-mail Address: Cell Phone:
Minority-owned or Female-owned Business:
Please indicate the counties you would be able to work in:
LICENSES (if applicable)
LEAD-BASED PAINT
Have you, or your firm, taken the Lead Renovation, Repair, and Painting traning?Please attach a copy of your Certificate of Completion
Give the type of license, license number, and expiration date.
Yes
Yes
Alleghany Ashe Avery Mitchell Watauga Wilkes Yancey
No
No
RELATIONSHIPS WITH LOCAL OFFICIALS
REFERENCES
CERTICIATION AND AUTHORIZATION
Give details regarding any relationship or ownership interest which exists between this company, or any individuals associated with it, and any employee, officer, or agent of Alleghany, Ashe, Avery, Mitchell, Watauga, Wilkes or Yancey County or High Country Council of Governments. If no relationship exists, please write "None".
I hereby certify the above information to be complete and correct to the best of my knowledge. I also certify that this company, and any individual having interest in it, is eligible to be awarded a government contract.
When complete return to: Michelle Ball
High Country Council of Governments 468 New Market Blvd.
Boone, NC 28607
If you have any questions or need more information regarding the program you may contact Michelle at (828) 265-5434 ext. 115 or [email protected]
Yes No
Date: