prequalificationform-newjersey.docVIP

Division of Procurement Bureau of Professional Services PS 11 PREQUALIFICATION FORM New FIRM Renewal PREPARED BY DATE Section 1 Prequalification General Information Format Firm’s Name, Address, Contacts, and Organizational Structure Firm 24 hour Emergency Contact Name Address Phone Federal ID Number Phone DUNS Number Fax DUNS Address Prequalificaton Contact CES Contact E-mail address E-mail address TYPE OF ORGANIZATION: CORPORATION PARTNERSHIP INDIVIDUAL OTHER If CORPORATION complete the following: If PARTNERSHIP complete the following: Date Incorporated Date Organized State Incorporated TYPE: GENERAL LIMITED OTHER Year Authorized in NJ Name and Title of Partners President’s Name Principals of the Firm (Names and Title) Certificate of Authorization Issued by NJ Division of Consumer Affairs State Board of Professional Engineers and Land Surveyors Certificate Number Date Issued Firm’s Former Name(s) Parent Company’s Headquarters Address Present Branch Office(s) Address Phone Person(s) in charge Fax Address Phone Person(s) in charge Fax Number of Professional/Technical Staff in the organization In NJ In Other Locations Current Strength Year Section 2 Prequalification Discipline List Response Format Instructions: In column A, indicate with an “X” all of the disciplines that your firm is requesting prequalification. Certificate of authorization is not required for disciplines marked “E” under Exempt. To view/apply for discipline(s) requirements (Section 3) click on the