2017 Small Works Roster Form
Statement of Qualifications
Unified Business Identifier / WA State Tax registration No.
Mailing City State and Zip
Phone Number (Incude Area Code xxx-xxx-xxxx)
After Hours No. (Emergency Contact)
WA Contractor's License?
WA Contractor's License Number
If No Contractor's License, Business License Number
WA Labor & Industries Workers' Comp Number
WA Employment Security Number
Federal Employment Tax ID Number
Electrical Contractors Licence Number. (If Applicable)
Firm must hold an active WA State Department of Revenue Account
The contractor shall certify that they are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participating in covered transactions by any State or Federal department or agency.
Insurance Agent Name
Insurance Phone Number
NOTE, Contractor must be able to provide as a minimum, the following insurance policy:
Automobile liability of $1,000,000 covering all owned, non-owned, hired, and leased vehicles; commecial general liability of $1,000,000 single limit and $2,000,000 agregate; and, if applicable, professional liability insurance of $1,000,000
Company must submit a copy of their certificate of liability insurance to qualify for the City of Camas Small Works Roster
Certificate of Liability Insurance (Word or PDF Only, Please limit size to 5MB)
Bonding Company (Required if Licensed Contractor)
Bonding Agent Name
Bonding Phone Number
Small or Disavanteged Business Certification (DBE)
DBE Business Status
DBE Business Status Certification Number
Attach DBE Business Status Document (Word or PDF Only, Please limit size to 5MB)
If you can not attach your DBE certification document now select your intent
Attached to Form
Bring to City Hall
Email to Ronda Syverson
Mail to Ronda Syverson
Per City of Camas Ordinance No. 2626, as a condition for the award or renewal of any contract after January 1, 2012, the Contractor shall enroll in the E-Verify program through the United States Department of Homeland Security and thereafter shall provide the City a copy of the Memorandum of Understanding (issued by Homeland Security), submitted with their bid proposal, affirming their enrollment and participation in the program. The Contractor shall be required to continue their participation in the program throughout the course of their contract with the City. Prime contractors shall require and verify that each of their subcontractors and lower tiered subcontractors are also enrolled and participants in the E-Verify program. This is intended to be used exclusively for employees hired after award and for the duration of the contract with the City of Camas. Please go to the Engineering page of the City of Camas web site at www.cityofcamas.us for additional information and to view Ordinance No. 2626.
E-Verify, is an Internet based system operated by the Department of Homeland Security in partnership with the Social Security Administration at no charge. E-Verify has been determined to be a suitable means for determining employment eligibility of new hires and the validity of their Social Security numbers. Please visit the Department of Homeland Security's web site at http://www.dhs.gov and select E-Verify to learn more or to enroll in this program.
Is your company enrolled in E-Verify?
I have read the E-Verify information and understand that the City of Camas will not enter into a contract without confirmation of enrollment and participation in the E-Verify program.
As provided by Title VI of the Civil Rights Act of 1964, and the Civil Rights Restoration Act of 1987, the contractor, with regard to the work performed by it during the contract, shall not discriminate on the grounds of race, color, religion, sex or national origin in the selection and retention of sub-contractors, including procurement of materials and leases of equipment.
Interested Area(s) of WorkCheck the appropriate boxes below for the area(s) of work you are interested in performing. Please list 3 references for each interested area of work at the bottom of the form. If you have done work for the City of Camas in the area checked, no reference is necessary. Also, list any comments about the scope of work in each area checked in the comment section below.
Interested Area(s) of Work
Concrete Curbs and Flatwork
Earthwork and Excavation
Hazardous Material Abatement
Plumbing – Residential and Commercial
Septic Tank Pumping
Sewer Cleaning and Video Inspection
Underground Utilities (Water, Sewer, Drainage)
Other(i.e., boring,tapping, painting, guardrail, etc.)
If Other is selected above, please list areas(s) of work
Comments (500 chars left)
Company is allowed to submit supplemental firm qualifications, experience, areas of expertise, and other relevant information. Submittal is not to exceed twenty (20) pages. Please attach document or email to Ronda Syverson firstname.lastname@example.org. You may also mail this information to Ronda at City of Camas, PO Box 1055, Camas, WA 98607.
Attach Supplemental Qualifications (Word or PDF Only Please 5MB Size Limit)
List Equipment Owned or Leased by Contractor
Please Type The Letters You See In the Box For Verification
Thank You for submitting the Small Works Roster Form. You will get a confirmation E-Mail shortly. Please contact Ronda Syverson email@example.com if you have any further questions about the process.
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