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APPLICATION INFORMATION FORM This page must be filled out and returned with your application. Failure to do so may subject your application to rejection. Unsigned Applications will NOT be considered. By signing this form, the potential subcontractor certifies the following: (Please initial each item.) This application is signed by an authorized representative of the firm; The potential subcontractor certifies that neither it nor any of its principals is presently debarred, suspended, proposed for debarment, declared ineligible, nor voluntarily excluded from participation in this transaction by any State and /or federal department or agency and that it does not have any overdue tax debts at the federal, State or local level. The potential subcontractor will maintain the required coverage and minimum insurance limits for the duration of the contract and agrees to provide certificates within ten (10) days of any verification request and add the State Energy Office as a certificate holder on all relevant policies; All labor costs, direct and indirect, have been determined and included in the proposed cost. The availability of all equipment, materials and supplies associated with performing the services described herein have been determined and included in the proposed cost. The potential subcontractor has read and understands the conditions set forth in this Invitation to Submit Applications and agrees to them with no exceptions. Therefore, in compliance with this Invitation to Submit Applications, and subject to all conditions herein, the undersigned offers and agrees, if this application is accepted within one hundred twenty (120) days from the date of the opening, to furnish the subject services. NAME OF ORGANIZATION: ADDRESS: CITY, STATE, ZIP: TELEPHONE: EMAIL: FACSIMILE: Principal Place of Business, if different from above: FEDERAL EMPLOYER IDENTIFICATION NUMBER: DUNS NUMBER: E- PROCUREMENT REGISTRATION? Will any of the work under this contract be performed outside the United States? (If yes, describe in technical application.) ❑ YES ❑ NO ❑ YES ❑ NO N.C.G.S. § 133 -32 and Executive Order 24 prohibit the offer to, or acceptance by, any State Employee of any gift from anyone with a contract with the State, or from any person seeking to do business with the State. By execution of any response in this procurement, you attest, for your entire organization and its employees or agents, that you are not aware that any such gift has been offered, accepted, or promised by any employees of your organization. SIGNED NAME (PRINTED): Solicitation No. 2011WXSSP TITLE: DATE: Page 21 of 53 Attachment number 1 F -4 Page 133