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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 yeazs. This list should be in sufficient detail to explain the <br />positions of the various parties and the ultimate outcome as to the damages awazded (if <br />any). This list shall be considered material as respects the fmal 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 information requested by the OWNER in verification of the recitals <br />comprising this Statement of Bidder's Qualifications <br />Dated at , this day of 20 <br />Name of Bidder <br />By: <br />Title: <br />STATE OF <br />COUNTY OF <br />, of <br />being duly sworn, deposes and says that he is <br />and that the answers to the foregoing questions <br />(name of contractor) <br />and all statements therein contained aze true and correct. <br />Subscribed and sworn to before me this day of , 20 <br />Notary Public <br />My commission expires: <br />21 <br />126 <br />