_________________________________________ _________________________________________
____________________________________________________________________________________
__________________________________
Waiver Request Form
One Form Per Project Only
Date: _________________________
Name of Company: ____________________________________________________________________
Address:
City: State: Zip:
Contact Person:
Phone Number: ___________________________
Fax Number: _____________________________
Original Signature and Date
Please check all that apply:
MASSDOT Prequalified Yes No
DCR Yes No
Email Address: _____________________________
Vendor Code:_______________________________
Print Name and Title
DCAMM General Bid Yes
No
DCAMM Filed Sub-Bid Yes No
*DCAMM General and Sub Contractors must submit an electronic copy of their DCAMM Certificate of Eligibility
Class of Work
Project Number
City / Town
Bid Opening Date Project Value
Scope of Work
____________________________________________________________________________________
____________________________________________________________________________________
Email this form to: prequal.r109@dot.state.ma.us
FOR OFFICIAL USE ONLY
Approved_________ Denied_________
Comments_________________________
MASSDOT, Highway Division
Prequalification Office
10 Park Plaza, Room 6260
Boston, MA 02116
Phone: 857-368-8660
Fax: 857-368-0643
Rev. 12/2018
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