1. Your Details
* Company Name:
* Mailing Address:
* City:
* State:
Zip Code
* F.E.I.D No.:
* Contact Name:
Title:
* Office Phone 1:
Office Phone 2:
Home Phone:
Mobile Phone:
Pager:
Fax:
Email:
 
2. Contractor Business Type
Is your company A:
(check all that apply) 		Name of Certifying Agency Certificate Number Application in Progress
HUB (Historically Underutilized Business)
DBE (Disadvantaged Business Enterprise)
WBE (Women Owned)
MBE (Minority Owned)
Small Business
SWAM (Small, Women, and Minority)

If your company is certified as one of the above, please fax a copy of the certificate(s). Click here to download a fax cover sheet.
If your company is not certified, is your company interested in becoming certified as one of the above?
3. Type of Work Performed

A-Pavement Maintenance
Parking Lots
Shoulder Surfaces
Pavement Surfaces-Asphalt
Pavement Surfaces-Concrete
Escape Ramps
Traffic

B-Roadside Maintenance
Curbs and Gutters
Fences
Walls-Barrier
Raised Medians
Overlooks Rock Outcroppings
Sidewalks and Bike Paths

C-Drainage
Drainage Structures
Ditches
Culvert
Storm Sewers
Underdrains

D-Vegetation and Aesthetics
Mowing
Landscapes

E-Traffic Services
Signal Lighting
Emergency Call Boxes
Symbols
Signs and Sign Post
Guardrail
Attenuators
Glare Foils
Reflective Markers
Striping
Lighting, Highway -Street

G-Highway Facility Maintenance
Utilities
Other Facilities (Custodial)

H-Bridge Maintenance
Bridges
Slope Protection

J-Snow
Snow/Ice Removal

X-Emergency
Hurricanes, Etc.
 
Please Specify Other:
4. Work Areas of Interest

Alaska
Whittier Tunnel Project
Ted Stevens Anchorage Airport

Florida
OOCEA Tollroad - SR 429 Apopka
Emerald Coast - State Roads South of I-10 – Santa Rosa, Okaloosa and Walton Counties
Pompano Beach - US1, A1a, and all movable and fixed Bridges – St. Lucie, Martin, Palm Beach and Broward Counties
Indian River - US1, A1A, SR 60 and SR 510
MDX-Miami Dade Expressway - SR836 – Dolphin, SR112 – Airport and SR 874 Don Shula Expressway, SR 878 Snapper Creek and SR 924 Gratingy Parkway
Monroe County
Monticello - State Roads in Jefferson, Franklin, Liberty, Wakulla and Gulf Counties
Movable Bridges - Includes bridges in Flagler, Volusia, Brevard, and Indian River Counties
Osceola - Rt. 192 - Includes the “Gateway to Disney”
Polk County
Space Coast - I-95 in Flagler, Volusia, Brevard and Indian River Counties. Also SR 528, SR 40 and SR 407
Tampa - I-4, I-175, I-275 and I-375 in Hillsborough and Pinellas Counties
Turnpike - Mile Marker 200-309
Clay County
Nassau County

Maryland
Maryland 100 - Howard and Arundel Counties

Texas
Waco
TX-130

Virginia
TAMS - Richmond Project
895 - Pochahontas Parkway

Washington, DC
Tunnel Project
 
5. Comments or Additional Information
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