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INDIAN RIVER COUNTY, FLORIDA <br />SEALED BID NO.2008081 <br />PROJECT NO. 0216 <br />12th STREET SIDEWALK IMPROVEMENTS FROM 16th AVE TO 111h PLACE <br />CONTRACTOR VERIFICATION FORM <br />THE FOLLOWING IS TO COMPLETED BY PRIME BIDDER: <br />Name of Firm: <br />Corporate Title: <br />Address: <br />By: <br />(Print name) <br />(Authorized Signature) <br />Telephone: ( ) <br />Fax: ( ) <br />State License # <br />County License # <br />City License: (ATTACH PROOF OF REGISTRATION WITH THE CITY) <br />Type of License: <br />Unlimited <br />If "NO", Limited to what trade? <br />(yes/no) <br />(Zip Code) <br />(Print title) <br />(ATTACH COPY) <br />(ATTACH COPY) <br />F:\Engineering\Capital Projects\0216-12th Street Between 16th Avenue and 1 lth Place\0216 Federal Contract Provisions.doc P-60 <br />Contractor Verification <br />