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17. Credit available. <br />18. Give three credit references, one of which must be a financial institution. <br />19. State the name and address of each of your Workmen's Compensation insurance carriers <br />for the last 5 years. <br />20. List each claim made against you by your employees or third parties for personal injury, <br />death, or property damage in each of the last 3 years. <br />21. List any and all litigation including arbitration, administrative proceedings, and mediation <br />in which you have been a plaintiff or defendant involving any owner, architect or <br />engineer over the past 5 years. This list should be in sufficient detail to explain the <br />positions of the various parties and the ultimate outcome as to the damages awarded (if <br />any). This list shall be considered material as respects the final awarding of any coiltract <br />connected with the bid. (State "none" or submit information on attached sheet). <br />22. The undersigned hereby authorizes and requests any person, firm, or corporation to <br />furnish any infornlation requested by the OWNER in verification of tlie recitals <br />comprising this Statement of Bidder's Qualifications <br />, <br />Dated at 7~ tl~is ~6~ day of <br />S?!9'' ~'f r`,S '~6•~' S z~~ c,~✓~~~ <br />Name of Bidder <br />By: <br />Title: l1 ~rV <br />STATE OF t-1--~1 <br />COUNTY OF ~ ~ ----1--- ✓ <br />4~,~, 5(,_, , being duly sworn, deposes and says that he is <br />of 5'~-.,~~~,,,~ and that the answers to the foregoing questions <br />(name of contractor) <br />and all statements therein contained are true and correct. <br />~ <br />Subscribed and sworn to before me this vday of U <br />W44 ~Y ~P • <br />~C/~•~~~P~ ~e~~0'~~ <br />. , <br />o-2~~ <br />4 <br />Notary ublic <br />My commission expires: <br />20 <br /> <br />0 0 el <br />