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17. Credit available. <br />18. Give three credit references, one of which must be a financial institution. <br />19. Sta.te the name and address of each of your Workrnen's Compensation insura,nce cazriers <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 properiy damage in each of the last 3 years. <br />21. List any and all litigation including arbitration, administrative proceedings, and mediation <br />in wluch 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 vazious 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 />, fumish any information requested by the OWNER in verification of the recitals <br />comprising this Staternent of Bidder's Qualifications <br />Dated at this day of 20 <br />Name of Bidder <br />By: <br />STATE OF <br />COUNTY OF <br />of <br />(name of contractor) <br />and a11 statements therein contained are true and correct. <br />Subscribed and sworn to before me this day of 20 <br />~ <br />Notary Public <br />My commission expires:. <br />Title: <br />being duly sworn, deposes and says that he is <br />and that the answers to the foregoing questions <br />21 <br />