Contractor Registration Forms Contracting with the Portage County Land Bank Step 1 of 6 16% CommentsThis field is for validation purposes and should be left unchanged.Basic InformationBusiness Name(Required)Primary Contact(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Email(Required) Business Type/ClassificationsBusiness Type(Required) Sole proprietorship LLC Corporation Other Business Classifications MBE (Minority Business Enterprise) WBE (Women Business Enterprise) Other How long have you been contracting under your current business name?(Required) ReferencesPlease provide three local references.Reference Name(Required) First Last Address(Required) City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Phone(Required)Reference Name(Required) First Last Address(Required) City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Phone(Required)Reference Name(Required) First Last Address(Required) City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Phone(Required) Area(s) of SpecialtyPlease select all that apply(Required) Asbestos inspection Asbestos remediation Board up and security Carpentry Concrete Demolition/Excavation Electrical General contracting Energy efficiency improvements HVAC Landscaping Lawn maintenance Lead abatement Masonry/Brick Painting Pest control Plumbing Trash out / Cleaning services Tree planting / Tree removal Waterproofing / Foundation services Other Licenses heldLicense Number/TypeLicense Expiration MM slash DD slash YYYY License Number/TypeLicense Expiration MM slash DD slash YYYY QualificationsHas your company ever been involved with any of the following? Does your company or any of its owners owe delinquent property taxes? Has your company ever defaulted on a contract? Has your company ever failed to complete work awarded to you? Is your company listed on the State of Ohio's debarment list or has it ever been? Is your company disqualified for work by a public organization or has it ever been? Has any kind of legal judgment been rendered against your company? Has your company ever filed for bankruptcy? If your company would answer yes to any of these questions, please explain in full. Your answers to these questions will be researched and failure to answer any of these questions truthfully will disqualify your company from all Land Bank work.Explanation(Required)Minimum Insurance Coverage/Worker’s CompensationTo pre-qualify for Land Bank work, your company must maintain and finish evidence of insurance and participation in Ohio’s worker compensation system. The minimum insurance expectations are (unless otherwise noted by the Land Bank): General liability (limit of liability $1,000,000 each occurrence, $2,000,000 aggregate) Automobile liability (limit of liability $1,000,000); and Worker’s compensation (with statutory limit). Contractors must include current insurance information with this form and will be responsible for providing updated insurance information after each annual renewal, a change in carrier, etc. Failure to provide this information now or in the future will disqualify the contractor from Land Bank work until corrected.Completed IRS W-9 form(Required)Max. file size: 128 MB. Certificate of insurance with land bank as additional insured(Required)Max. file size: 128 MB. Copy of current Ohio worker's compensation certificate(Required)Max. file size: 128 MB. Digital signature(Required)I certify that the information provided in this form is, to the best of my knowledge and belief, true, accurate, and complete. I have read the contractor terms and conditions available above, and I am authorized on behalf of the company to agree to such terms and conditions by my signature below. Δ Have questions? Want to get involved? Send us a message. Contact Us
