Fill - Free fillable SUBCONTRACTOR APPROVAL FORM 1105 (New Jersey Schools Development Authority) PDF form

Revised Edition 12/15

Page 1 of 2

NJSDA Form 1105

Been indicted or otherwise charged as a defendant, or named as an unindicted co-conspirator, alleged to

have committed any crime or offense other than a motor vehicle offense?

For NJSDA Use Only

NJSDA Contract #:

Contract Amount:

District Name:

School Name:

County:

SUBCONTRACTOR APPROVAL FORM 1105

ALL SECTIONS OF THIS FORM MUST BE COMPLETED - please type or print clearly

Subcontractor Name:

Street Address:

E-mail Address:

Phone:

Contact Name:

MBE

WBE

(check all that apply and attach certification)

School: NJSDA Contract #:

Subcontracted Trade:

Subcontracted Amt:

Tier #:

Anticipated Start Date: Anticipated End Date:

Trade Licenses Held:

Licensee Name Trade/License # Exp. Date

Plumbing

Electrical

Asbestos

Fire Suppression

Other (Trade & #)

Been convicted, after trial or by plea, of any crime or offense other than a motor vehicle offense?

Been suspended, debarred, disqualified, denied a classification rating or pre-qualification or otherwise been

declared not responsible to bid on or to perform work on any public contract or subcontract?

Been denied any license, permit or other similar authorization required to engage in the business concern's

trade(s) or professional discipline(s), or has any such license, permit or similar authorization been

suspended or revoked by any agency of federal, state or local government?

* If yes to any of the above, please provide details on a separate attachment.

Yes* No

City:

Zip:

County:

Prime Contractor Name: E-mail Address:

At any time during the past ten (10) years, has the subcontractor:

Federal Tax ID #:

State:

Reviewed by PMF/CM:

Reviewed by NJSDA PM: Date:

Date:

(signature)

32 EAST FRONT STREET

P.O. BOX 991

TRENTON, NJ 08625-0991

609-858-5325

VOB

SBE

Revised Edition 12/15

Page 2 of 2

NJSDA Form 1105

CERTIFICATION: I, being duly sworn upon my oath, hereby represent and state that the foregoing information and any attachments

thereto to the best of my knowledge are true and complete. I acknowledge that the NJSDA is relying on the information contained herein

and that all information submitted to the NJSDA remains valid and correct. I acknowledge that I am under a continuing obligation from the

date of this certification through the completion of any contracts with the NJSDA to notify in writing of any changes to the answers or

information contained herein. I acknowledge that I am aware that it is a criminal offense to make a false statement or misrepresentation in

this certification, and if I do so, I recognize that I am subject to criminal prosecution under the law and that it will also constitute a material

breach of my agreement(s) with the NJSDA and that the NJSDA at its option, may declare any contract(s) resulting from this certification

void and unenforceable.

I, being duly authorized, certify that the information supplied above, including all attached pages, is complete and correct to the best of my

knowledge.

In addition to the Subcontractors required to be named with the bid submission, subcontractors of any tier in the DPMC Trade

Classifications listed below whose contract is in an amount which is equal to or greater than $500,000 be pre-qualified by the

NJSDA.

C006-Construction Manager, C007-Design Build, C008-General Construction, C009-General Construction/Alterations & Additions, C019-

Concrete/Foundation/Footings/Masonry work, C021-Demolition, C029-Structural Steel & Ornamental Iron, C030-Plumbing, C032-

HVACR, C045-Sprinkler Systems, C047-Electrical, C066-Roofing-Membrane EPDM, C067-Roofing-Membrane PVC/CPE/CSPE, C068-

Roofing-Membrane Modified Bitumen, C069-Roofing-Urethane, C070-Roofing Built Up, C071-Roofing-Metal, C072-Roofing-Tile/Slate/

Shingles, C076-Roofing/TPO, C092-Asbestos Removal/Treatment, C093-Asbestos Removal/Mechanical, C096-Lead Paint Abatement

For NJSDA Use Only

NJSDA Contract #:

NOTARY: Sworn to and subscribed before me

this day of

Signature:

Signature: Name (Print):

My commission expires on:

(Notary Public: Not an officer of the firm)

Title (Print):

For NJSDA Use Only

NJSDA Pre-qualification Exp. Date: Trade(s):

Trade(s):

DPMC Classification Exp. Date:

NJ Dept. of Labor - Public Works “Contractor Registration Act Certification” Exp. Date:

NJ Dept. of Treasury - Division of Revenue “Business Registration” Issue Date:

Date Submitted to State Police:

Date Approved by State Police:

Date Approved by NJSDA:

RM/VS Approval:

Risk Management & Vendor Services approval

signifies that verification revealed no reason to deny

approval to the Subcontractor reviewed and

submitted by PMF / NJSDA Project Manager.

Date Denied by State Police:

NJ State Debarment List:

Yes No

SUBCONTRACTORS ON SDA MANAGED PROJECTS OF $5M OR MORE ARE UNDER THE PROJECT

LABOR AGREEMENT (PLA): All tier subcontractors on PLA designated projects, performing PLA regulated

work, shall submit a copy of the executed, Letter of Assent (LOA) and attach to the Subcontractor Approval Form

1105 as a condition of approval. Subcontractors of any tier whose proposed work is regulated by the PLA, and who

are found to be non-compliant after the start of any such work may have their approval revoked and/or may be

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