2. Contractor Name
4. Address
6. City
7. State
8. Zip Code
10. Phone Number
11. Fax Number
13. Email Address
15. Organization Type

    1. Corporation
    2. Partnership
    3. LLC/LLP
    4. Individual
16. State of Organization
17. Years business has been organized
19. Company's Bonding Limits
21. Per Project
22. Aggregate
23. Name of Bonding agent
25. Attach completed W9 (N/A if already a vendor with Lenawee County)
26. Certificate of liability insurance
28. References /Credentials
30. Drain Commissioners
    Please list the county drain commissioners you are currently working for, or have worked for in the past 3 years, and contact person;
32. Other Municipalities
    Please list other municipalities/references you are currently working for, or have worked for in the past 3 years. and contact person;
34. Pre-Qualifications
    Please list any pre-qualifications you have, if any( i.e. MDOT, City of Adrian)
36. Failed work
    Has your company ever failed to complete any work awarded to you? If so, where and why?
38. Failed Work
    Has any officer or partner of your organization ever been an officer or partner of some other organization that failed to complete a construction contract? If so, state name of individual, other organization, and reason for not completing contract (Attach a letter if needed)
40. Drain Construction Abilities
    Please check the type of work your company has the equipment, manpower, and experience to complete:
42. Enclosed Drain

    1. Storm Sewer, up to 5' deep
    2. Storm Sewer, 5' to 10' deep
    3. Storm Sewer, deeper the 10'
    4. Sewer Televising
    5. Sewer Jetting, Hydro Excavation
    6. Pipe lining/grounding
    7. Directional boring
43. Open Drain

    1. Open drain cleanout
    2. Licensed herbicide contractor
    3. Woody debris management
    4. Brush mowing
    5. ROW/Easement clearing
    6. Landscaping/Restoration Work
44. Other

    1. Asphalt paving
    2. Concrete work/repair
46. Other Experience
    List other areas of experience you believe would be applicable to drain maintenance:
48. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
50. Electronic Signature
    I, the undersigned, in applying to be placed on the Pre-Qualified Contractor’s List for non-petitioned maintenance, certify and attest that the above provided information is, to the best of my knowledge, true and accurate.
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52. 1. Receive an email copy of this form.
53. Email address

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