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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