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- ra- rax: (tlee) 994-2338 TO' a19037850308 FBX: +19037850308 Page 3 of 9 4r*120104A3 <br />17. Credit available. <br />18. Give three credit references, one of'which must be a fmancial institution, <br />.SeF <br />19. State the name and adciress af c;ach of your Workmen's Compensation insurance carriers <br />far the lak-5 years, <br />ln r;,,,2nr~, -)?C 8o7c <br />20. List each claitn mad against you by your employees or third parties for personai iqjury, <br />death, or properiy damage in each of the last 3 years. <br />M:A .e <br />21. List any and all litigation includinb arbitration, administrafive proceedizzgs, and mediation <br />in which you have been a plaintiff or defendaut involving any owner, architect or <br />engineer over the pasr 5 years. This list shoutd be in suffieieni 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 awatding of any eontract <br />connected with.the bid. (State "none" or submit infornnation an attached sheet). <br />h°o-r 4 <br />22. The undezsigned hereby authorizes and requests any person, finii, or corporation ta <br />fwnish any infarmatian requested by the OWNER in verification of the recitals <br />comprising this Siatemeni of Bidder`s Qualifications <br />Dated at th13 !~T~' day of '41e/L <br />` 298 2oio <br />STATE OF "XAC <br />COUNTY OF _ Cot.t_1 ,v <br />Name of Bid <br />By: / <br />R[s MILx- P iTTAf-p , being, duly swom, deposes and says that he is <br />pj~-S i t~v~rt- , of PtiTr,~" p and that the answers to the foregoing questions <br />(name of contractor) <br />and all statements iherein contained aze true and correct. <br />Subscribed and swom to before me this T" day of ^"t-~-4. c._. rI*.. <br />2.a ~Nota <br />Mz~ cires: /I-v6 M Z6r 2-o ! o <br />STATE OF lExAS <br />~tOF MY C°^m 4 ArpnM ti. 2010 <br />n,a - t) <br />