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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 tlzird 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 contract <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 infonnation requested by the OWNER in verification of the recitals <br />comprising this Statement of Bidder's Qualifications <br />~ / <br />Dated at ° ~ 7J this /4l~ ~ jS~ day of ~ f ~ ~ ' ~ <br />4 <br />STATE OF / <br />COUNTY OF ~ ~ <br />~ <br />S~iy~?rn~ G.~S ~~,~-yl (✓~✓L <br />Name of Bidder <br />By: <br />Title:~i~ <br />being duly sworn, deposes and says that he is <br />of and that the answers to the foregoing questions <br />` (name of contractor) <br />and all statements therein contained are true and correct. <br />„ c- IJ <br />Subscribed and sworn to before me this c,).- day of /C, <br />W n4 <br />YPU• <br />. <br />; <br />•.E7CP RES•' or- <br />$ <br />.08'20- <br />""0111111101% <br />Notary Public <br />My conimission expires: <br />20 <br />