Revised 6/30/17
REQUEST FOR OFFICIAL PROPOSAL FORM (R109)
Date: ________________________________
Name of Company: ____
Address:
City: State: Zip:
Contact Person:
Phone Number: ____________________________ E-mail Address:
Vendor Code: _____________________________
Original Signature, Title and Date
R109 form must be signed by an authorized representative of the company. In accordance with 720 CMR Section 5.04 (2) and under the
penalties and perjury, I certify that the above combination of the project value plus the firm’s uncompleted work does not exceed the firm’s
aggregate bonding capacity. CSD-681 (R109) (REV. 09/18/2012)
MASSDOT Prequalified
DCAMM General Bid
DCAMM Filed Sub-Bid
*DCAMM General and Sub Contractors must submit an electronic copy of their DCAMM Certificate of Eligibility
Please email the R109 form to: prequal.r109@state.ma.us
or Fax this form to: 857-368-0643
Questions? Call (857) 368 – 8660
click to sign
signature
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