COMMONWEALTH OF PENNSYLVANIA
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF TRANSPORTATION
BUREAU OF CONSTRUCTION & MATERIALS
PREQUALIFICATION OFFICE
400 NORTH STREET – 7TH FLOOR WEST
HARRISBURG, PENNSYLVANIA 17101-1900
dot.state.pa.us
APPLICATION FOR PREQUALIFICATION
FORM CS- 4300 COVER SHEET
The Application for Prequalification of Contractors to bid and perform work to be done under the direction of the Department of Transportation contains the following three Parts:
PART 1 - Contractor’s Financial Statement
PART 2 - Organization and Experience Statement
PART 3 - Affirmative Action Statement.
Please check the appropriate block and submit this Cover Sheet and the requested Parts of the Application/Renewal for Prequalification.
Contractor
Prequalification No. (if renewal) ________
Business Partner Registration No. _______________________________________________________
PRIME CONTRACTOR
❑ New Application - Submit Parts 1, 2 and 3 in total.
❑ Renewal Application with no request for additional work classifications - Submit
• Completed Part 1
• Part 2*, Page 1 and Part 2, Page 13
• Part 3, Page 1 and Part 3, Page 6
❑ Renewal Application with request for additional work classifications - Submit
• Completed Part 1
• Completed Part 2
• Part 3, Page 1 and Part 3, Page 6
SUBCONTRACTOR
❑ New Application - Submit Parts 2 and 3 in total.
❑ Renewal Application with no request for additional work classifications - Submit
• Part 2*, Page 1 and Part 2, Page 13
• Part 3, Page 1 and Part 3, Page 6
❑ Renewal Application with request for additional work classifications – Submit
• Completed Part 2
• Part 3, Page 1 and Part 3, Page 6
*Entire Part 2 is required if there are any changes to the Corporate Structure, Ownership, Company name, Federal ID No., and any changes to related questions identified in Title 67 Transportation, Section 457.4 (c), Prequalification of Bidders.
Contractor
Business Address
Street P.O. Box No.
City State Zip Code
Telephone Number ( )
Fax Number ( )
Internal Revenue Service ID No.
(Employer ID / SSN)
Pennsylvania Resident Agent For
Out-of-State Contractors
Name
Business Address
Street P.O. Box No.
City State Zip Code
NOTE: The Department reserves the right to request additional information for prequalification at any time as per the requirements of Title 67 Transportation, Section 457.17, Notification.
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