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131030 Sewer Insurance Policy
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131030 Sewer Insurance Policy
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Last modified
11/21/2013 8:53:53 AM
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11/21/2013 8:53:34 AM
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Board of Public Works
Document Date
11/12/2013
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Exhibit D <br /> APPLICATION <br /> PRE-QUALIFICATION FOR THE CITY OF SOUTH BEND, INDIANA <br /> SEWER INSURANCE PROGRAM <br /> Name of Company: <br /> Pre-Qualification Category <br /> Second Opinion Excavation Special <br /> ❑ ❑ ❑ <br /> Attach copies of the following documents: <br /> 1. License Number <br /> 2. Bond letter stating limits for single project and aggregate program <br /> 3. (Corp. or LLC Only) Corporate authority and/or proof of registry with the Secretary of State to do <br /> business in Indiana <br /> Principal Place of <br /> Business: <br /> Mailing Address: <br /> Telephone: Cell: Fax: E-Mail: <br /> Ownership Information <br /> (Identify all owners if the <br /> Company,if applicable) <br /> Nature of Company's <br /> Business <br /> (Briefly describe the type of <br /> services your company provides) <br /> (Provide references as needed to <br /> validate experience for specific <br /> pre-qualification) <br /> License Information <br /> (Nome of holder,license type, <br /> number) <br /> 12 <br />
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