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, 2021 – December 21, 2021)
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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