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State of North Carolina <br />Prequalification for Single Prime Contractors <br />4. Signature <br />By signing this document, you are acknowledging that all answers are true to the best of your knowledge. <br />Submitted by: <br />Company Name (as licensed in NC) <br />Physical Address <br />Mailing Address <br />a. Dated this day of: <br />Submitted by: <br />Signature by Authorized Officer Print Title of Authorized Officer <br />Phone: <br />Contact person's phone number <br />Email: <br />Contact person's E -mail address <br />b. Notary Certification: <br />North Carolina <br />County <br />I, a Notary Public of the County and State aforesaid, certify that personally <br />appeared before me this day and acknowledged the execution of the foregoing instrument. Witness my <br />hand and official seal, this the day of 1 20 <br />Official Notary Seal or Stamp) <br />Signature of Notary Public <br />My commission expires , 20_ <br />Prequalification_Form_03 -01 -11 12 of 12 <br />Attachment number 3 <br />F -1 Page 75 <br />