dpmc-27 03 07
dpmc-27 03 07
dpmc-27 03 07
PO Box 034
Trenton, NJ 08625-0034
DEPARTMENT OF THE TREASURY
DIVISION OF PROPERTY MANAGEMENT AND CONSTRUCTION
ATTENTION CONTRACTOR
Enclosed is the Contractors Request for Classification Booklet (DPMC 27) which, when completed and submitted with the mandatory
financial statement and other documentation provides the data required to post your firm on the active bid list for State projects
described herein.
Please submit the completed application and all required documentation to this office. Upon review and approval of this application,
your firm will be notified by mail of the effective and expiration dates, type of work, and rating assigned to your firm.
There is a non-refundable fee of $100.00 which must be submitted with the application. All payments must be made on company
checks (no-cash) made payable to "Treasurer, State of New J ersey". No application will be processed without the fee.
If you have any questions, please contact the Contractor Classification unit at (609) 943-3400 (and select #3) or access the DPMC
web site at www.state.nj.us/treasury/dpmc/. NOTE: It is suggested that a photocopy of this completed form be retained for your
records.
(DPMC-27) - 08/03
Page 1 of 10
REQUEST FOR CLASSIFICATION (DPMC27)
STATE OF NEW J ERSEY - DIVISION OF PROPERTY MANAGEMENT AND CONSTRUCTION
RETURN ALL FORMS AND FINANCIAL STATEMENTS TO:
DPM&C Contractor Classification
33 W State St, PO Box, 034 Trenton, NJ 08625-0034
FORM 1 - CERTI FI CATION, EXPERIENCE AND LICENSING Check One:
SUBMITTED BY
TELEPHONE NO
(___)_________
FAX NO
(___)_________
TYPE OF BUSINESS
SOLE PROPRIETOR
PARTNERSHIP
CORPORATION
If the books and accounts of the organization are not at the above address, enter location where they are
kept.
Is your firm certified as a
Minority Business Enterprise
Woman Business Enterprise with NJ Commerce Dept
Small Business Enterprise
CONSTRUCTION EXPERI ENCE
1. Name of Equal Opportunity Officer 2. Location of Equal Opportunity Officer
4. How many years has your organization been
in business as a contractor under
your present business name?
_____Years
5. Is your company owned by another firm?
NO YES (If yes, attach details)
6. Has your company been owned by
another firm in the past?
NO YES
7. Are any owners, partners or principals of your
company affiliated with any other firm(s) as
employees, shareholders or directors?
NO YES (If yes, attach details)
8. In the past 5 years, have any of the owners, partners, or principals of your company held similar positions
or been employees, shareholders or directors of a company engaged in the same or similar type of
business for which classification is sought?
NO YES
9. Give the number of years of experience in construction your organization has had in the trades entered here.
TRADE(S):____________________________________________________________________________________________________________________
________________________________________________________________ (a) As a prime contractor: ___ Years; (b) As a sub-contractor: ___ Years.
CONSTRUCTI ON EXPERI ENCE OF THE PRI NCIPAL I NDIVI DUALS OF YOUR COMPANY
INDIVIDUAL'S NAME
PRESENT POSITION
OR OFFICE
LENGTH OF TIME
EMPLOYED BY YOUR
ORGANIZATION
NO. OF YEARS
CONSTRUCTION
EXPERIENCE
BIRTH
DATE
SOCIAL
SECURITY #
NOTE: If more space is required for the principal individuals of your company, attach additional sheets.
THI S SECTION TO BE COMPLETED FOR A CORPORATI ON
Date incorporated: ______________________________ ; State in which incorporated : ______________________________________ ; NJ Corporate ID # : ________________________________________
IF NOT I NCORPORATED
I N NEW J ERSEY
Name of Registered Agent in New J ersey:
_________________________________________
Submit copy of current Certificate of Authority to perform work in
New J ersey as issued by N.J . Secretary of State.
LI CENSE I NFORMATI ON
TYPE OF LICENSE
LICENSE / CERTIFICATION
NUMBER
LICENSEE NAME (NOT COMPANY
NAME, MUST BE SAME AS LICENSEE)
EFFECTIVE
DATE
EXPIRATION
DATE
BIRTH
DATE
SOC SEC NO
ELECTRICAL
PLUMBI NG
WELL DRI LLI NG
ASBESTOS
LEAD PAI NT
ABATEMENT
UNDERGROUND
STORAGE TANK
SPRINKLER
SYSTEMS
E
B
(DPMC27 -03/ 07 Page 2 of 10
(If yes, attach details)
LLC
Title
Date
Fed ID #
Signature
of Officer
Renewal New
Signature
of Preparer Title
E-Mail Address
3. Percentage of contract work performed by
your own employees excluding
subcontracting _____%
FI RE ALARM/
SIGNAL
Contact Person :
Name : ____________________
Phone: ( ____)_______________
Landscape Irrigation
FORM 2STOCKHOLDER/COMMON DISCLOSURE
FIRM NAME FEDERAL ID NO
STATE OF NEW JERSEYDIVISION OF PROPERTY MANAGEMENT AND CONSTRUCTION
INSTRUCTIONS: List below the names, home addresses, dates of birth, social security numbers, offices held and ownership interest of all officers
and all individuals, partnerships, corporations or any other owner with 10% or more named on the preceding page. All questions must be
answered. If more space is needed, list on separate sheet.
NAME HOME ADDRESS
BIRTH
SOC SEC NO OFFICE HELD
PERCENT OF
DATE OWNERSHIP
PRESIDENT
VICE PRESIDENT
SECRETARY
TREASURER
COMPLETE ALL QUESTIONS BELOW YES NO
1. Is the firm identified above owned or affiliated with any other company and/or corporation or are any principals listed above
an owner or shareholder of any other company, partnership or corporation?
(If yes,complete a separate disclosure form for the parent company and/or affiliates.)
2. Has any agency of government experienced delay in completion, additional expense, liens or claims filed against the per-
formance or payment bonds in the past five years? (If yes, attach a detailed explanation for each instance.)
3. Within the past five years has the firm identified above been owned by another company or corporation?
(If yes, complete a separate disclosure form for the previous owner and/or affiliates.)
4. Has any person or entity listed in this application ever been arrested, charged, indicted or convicted of a crime by the State of
New Jersey, any other State or the U.S. Government? (If yes, attach a detailed explanation for each instance.)
5. Has any person or entity listed in this form ever been suspended, debarred or otherwise declared ineligible by an Agency of
Government from bidding or contracting to provide services, labor, material, or supplies? (If yes, attach a detailed explanation
for each instance.)
6. Have there been any administrative, civil or criminal matters pending in any federal, state, or local governmental jurisdiction
in which this firm or its responsible employees are involved? (If yes, attach a detailed explanation for each instance.) This also
includes any prevailing wage adjudications.
7. Has any federal, state, or local government license, permit or similar authorization necessary to perform the work applied for
herein and held or applied for by any person or entity listed in this form been suspended or revoked, or is it the subject of
any pending proceedings specifically seeking or litigating the issue of suspension or revocation? (If yes to any part of this
question attach a detailed explanation for each instance.)
CERTIFICATION: I, being duly sworn, upon my oath, hereby represent and state that the foregoing information and any attachments thereto to
the best of my knowledge are true and complete. I acknowledge that the State of New Jersey is relying upon the information contained herein and
thereby acknowledge that I am under continuing obligation from the date of this certification through the completion of any contracts with the
State to notify the State in writing of any changes to the answers or information contained herein. I acknowledge that I am aware that it is a crimi-
nal offense to make a false statement or misrepresentation in this certification, and if I do so, I recognize that I am subject to criminal prosecution
under the law and that it will also constitute a material breach of my obligations to the State of New Jersey and that the State, at its option, may
declare any contract(s) resulting from this certification void and unenforceable and take any other action including debarment, suspension, etc.,
that the State may deem appropriate. I, being duly authorized, certify that the information supplied above, including all attached pages, is com-
plete and correct to the best of my knowledge.
ATTESTED: Sworn and subscribed to before me SIGNATURE: ________________________ DATE: ____________
(Officer or Principal)
on the ______ day of ________________________, 20____ NAME: ________________________________________
(Please print or type)
Signature: ________________________________________ TITLE: __________________________________________
(Notary Public - Not an officer of the firm)
(DPMC-27)03/07) Page 3 of 10 Initials of Preparer ________
CORP
SEAL