Form Center

2. 
3. Community Development Block Grant

   
   REHABILITATION CONTRACTOR
   REGISTRATION APPLICATION
   
   

5. Date:*
   Date:

7. The undersigned contracting firm hereby applies to be placed on the “Acceptable Contractors Register” maintained by our office for the purpose of performing rehabilitation work in the City of Waukegan.  It is certified that the information given below is complete, factual, and that no unfavorable information has been withheld.

9. Business Name:*
11. Business Address:*
13. Description of Services:*
15. Telephone Number*
16. Cell Phone Number:*
18. Fax Number:
20. Email Address:*
22. Contractor's IRS Reporting Number:*

26. Name, addresses and years of construction experience of all owners, partners and stockholders. (Fields expanded as needed)

28. Names and addresses *
29. Years of Experience*
31. Other contracting firms or names under which the principles have operated with former addresses
35. Names and Addresses of the Following References (Fields expand as needed)
37. Banks:*
39. Material Dealers:*
41. Sub-Contractors*

43. List three (3) recent customers for which you have done major work.  Include name, address and telephone number.

45. Customer 1:*
47. Customer 2:*
49. Customer 3:*
53. Race Category (Select all that apply)*

    1. White
    2. Black/African American
    3. Asian
    4. American Indian/Alaskan Native
    5. Native Hawaiian/Other Pacific Islander
54. Ethnicity*

    Hispanic?

    1. Yes
    2. No

58. The undersigned contracting firm agrees that in consideration for being placed upon the “Acceptable Contractors Register” he/she will comply with the following conditions on all rehabilitation work performed on properties located within the City of Waukegan, regardless of whether federal financing is or is not used by the owner.

    1. To use only contract forms approved by the City of Waukegan and the Department of Housing and Urban Development.

    2. That work will be performed in accordance with the Rehabilitation specifications, subject to such inspections as deemed necessary by the City of Waukegan and the Department of Housing and Urban Development.

    3. That if work performed by the Contractor is found to be unsatisfactory by the City of Waukegan and the Department of Housing and Urban Development or if contract relations between the contractor, homeowner, or other parties is found to be unsatisfactory, that the City of Waukegan and the Department of Housing and Urban Development may remove the Contractor’s name from the “Acceptable Contractors Register”.

    4. That the contract will abide by Equal Opportunity provisions of the Civil Rights Act.

    5. Provide copies of adequate insurance:  Workman’s Compensation; and a Certificate of Insurance (as required by the City of Waukegan and the Department of Housing and Urban Development).

    6. Proof of current registration with a copy of your City of Waukegan Contractor’s License Card for the current fiscal year.

    
    

60. Firm's Name*
62. Authorized Signature*

    By typing my full name here, I agree that this stands as my electronic signature.

64. Title of Authorized Signature*
68. Once you click SUBMIT, you will be taken to the Vendor Registration Form. You will need to include the following documents with the form.
    • Certificate of Liability Insurance
    • License and Permit Bond
    • Portfolio of Rehab Work
Leave This Blank:


70. 1. Receive an email copy of this form.
71. Email address

    This field is not part of the form submission.

72. Submit

* indicates a required field