Laserfiche WebLink
If Sub-contractor is a sole proprietorship, list: <br /> Sub-contractor Name Phone <br /> Mailing Address <br /> City State Zip <br /> SSN EIN <br /> 6. VERIFICATION <br /> I certify under penalty of the Act (Public Law 95-87) that I <br /> am a responsible official (as identified in item 3 or 7) for <br /> this proposed operation, that I have personally examined and <br /> am familiar with the information submitted in this disclosure <br /> and all attachments, and that, based on my inquiry of those <br /> persons immediately responsible for obtaining the information <br /> contained in this disclosure, I believe that the information <br /> is true, accurate, and complete. I am aware there are <br /> significant penalties for submitting false information, <br /> including the possibility of fine and imprisonment (uS Code <br /> Title 18, Sec. 1001) . <br /> Signature of Responsible Officer <br /> Title Date <br /> Subscribed and sworn to before me by <br /> This day of 19 <br /> Notary Public <br /> My Commission expires: <br /> h _ _ <br />