Employment

Small Works Roster Application

APPLICATION FOR SMALL WORKS ROSTER

PORT OF INDIANOLA

PO BOX 496

INDIANOLA, WA 98342

PHONE 360-779-8229

smallworksroster@portofindianola.com

If you wish to be on the small works roster of the Port of Indianola the following application must be completed in all particulars. Incomplete applications will not be accepted.

You are notified that the Port of Indianola complies with the prevailing wage law of the State of Washington (RCW 39.12) and requires all contractors to comply.

Further questions need to be directed to smallworksroster@portofindianola.com.

 

ROSTER EFFECTIVE DATES: (January 1, 2015-December, 31, 2015)

1. Name of Company _____________________________ Phone #’s _____________________

2. Email address _____________________________________________

3. Business Address __________________________________________

4. City ____________________ State ________________ Zip code _______________________

5. Check Appropriate: _____ Incorporated _____ Partnership _____ Sole Proprietor

If incorporated, state resident agent and address. If partnership or sole proprietor, state person and address. __________________________________________________________

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6. Federal tax identification Number (TIN):________________________________

7. State Licensing information: _________________________________________

8. State of Washington Contractor’s Registration Number: ___________________

9. Contractor’s Bond information:

a. Name of Bonding Company _________________________________________

b. Amount of Bond ___________________________________________________

c. Bond Number _____________________________________________________

10. Licensed as (Check Appropriate)

_____ General Contractor

_____ Specialty Contractor (please state specialty/specialties or attach)

Date: _________________ By: _________________________

Title: _____________________________________

Please include a brief description of the services your company provide or attach documentation if preferred.

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