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I hereby certify that the information contained in this Prequalification Application is true and accurate to the best of my knowledge. Additionally, I certify that this company, nor its principals, is presently debarred, suspended, proposed for debarrment, declared ineligible, or voluntarily excluded from participation in Federal or State funded programs by any Federal or State department or agency.
In consideration of the City of Carbondale, Illinois processing my Prequalification Application for Contracting, I/we hereby voluntarily and knowingly execute this release of information, and hereby authorize the City of Carbondale to undertake a full and complete check to verify the information submitted on the Contractor's Prequalification Application.
I/we with the intention of binding myself, my heirs, executors, administrators and assigns releases and discharges the City of Carbondale, its officials, employees, agents, and all persons, companies or agencies contacted by the City of Carbondale to verify the Contractor's Prequalification Application information from all claims, demands, actions, judgements and executions which I/we ever had, or now have, or which my heirs, executors, administrators or assigns may have, or claim to have against the City of Carbondale, its officials, employees, and agents and all persons, companies, or agencies contracted by the City of Carbondale to verify the Contractor's Prequalification Application information arising out of the performance of any and all such verifications.
I/we further authorize the financial institutions, suppliers, material men, individuals and/or companies, firms, organizations, or other entities, that have or have had business relationships with Applicant, to disclose to the City of Carbondale such information as is necessary to verify the information I/we have provided in the Contractor's Prequalification Application.
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.
(Plumber, roofing, etc.)
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