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SMALL M/WBE INTENT TO PERFORM AS A

SUBCONTRACTOR FORM

(POTENTIAL PROFESSIONAL/CONTRACTOR/VENDOR TO IDENTIFY SUBCONTRACTORS SELECTED FOR WORK ON THE CONTRACT)

Prime Contractor:  _________________________________________________________________

Vendor Identification Number: _______________________________________________________

Address: _________________________________________________________________________

Phone: _____ - _____ - ________Bid Number: __________________________________

Contract Amount: $___________________

Description of commodities/specifications: _____________________________________________

________________________________________________________________________________

Time Period: _____________________________________________________________________

Name of Subcontractor/Supplier: _____________________________________________________

Address: _________________________________________________________________________

Phone: _____ - _____ - __________E-mail Address: ______________________________________

Is the subcontractor certified by NCTRCA?

Yes _____ No _____

Dollar amount of contract with this Subcontractor/Supplier: $_______________________________

Percentage amount of contract with this Subcontractor/Supplier: % __________________________

Description of work performed under agreement with the Subcontractor for amount indicated above: ______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

PLEASE SUBMIT A SEPARATE FORM FOR EACH SUBCONTRACTOR/SUPPLIER SERVICE

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