State Of Alaska Bidders Registration Form – Fill Out and Use This PDF

STATE OF ALASKA

DEPARTMENT OF TRANSPORTATION AND PUBLIC FACILITIES

Civil Rights Office – DBE Program

BIDDER REGISTRATION

All firms are required to submit a Bidder’s Registration form before an Alaska Department of Transportation and Public Facilities (DOT&PF) project can be awarded. The Bidder Registration form must be submitted to the Civil Rights Officer (CRO) on an annual basis by January 1 and is valid thru December 31. Complete this form for each contractor and subcontractor. Firms will be listed on the bidder registration online directory http://www.dot.state.ak.us/cvlrts/bidreg.shtml.

Name of Firm:

Street Address:

Mailing Address:

Contact Name:

Telephone Number:

Fax number:

E-mail Address:

Date Firm was Established:

The firm listed above is a (check all that apply):

Prime Contractor?

< $500,000 $500,000- $999,999

$1,000,000- $4,999,999 $5,000,000- $9,999,999 $10,000,000- $16,999,999 > $17,000,000

Type of contracts/proposals bid by the firm (check all that apply):

Signature of Company Representative	Title	Date
Send this completed form to:	OR	You may fax your completed form to:
ADOT&PF Civil Rights Office		(907) 269-0847
PO Box 196900
Anchorage, Alaska 99519-6900

If you have any questions, please call (907) 269-0851.

Form 25D-6 (1/16)

SMALL BUSINESS ENTERPRISE PROGRAM (SBE) SELF-REGISTRATION

Fostering Small Business Participation (SBE) (49 CFR 26.39):

To meet the requirements of 49 CFR 26.39, DOT&PF has implemented a Small Business Enterprise Program. This component is only applicable to federally funded projects.

[Complete the Section below only if you are a Self-Certified SBE Firm] All businesses wishing to be eligible as a SBE are required to submit a SBE Self-Registration form. The SBE Self-Registration form must be submitted on an annual basis by January 1 and is valid thru December 31.

In order to verify your firm’s compliance with business size standards under 49 CFR 26.67(2)(i) and 26.65(b), at the

time of award you will be required to submit the following documents:

●SBE Affidavit of Certification Eligibility

●Personal Financial Statement

●Past three years of your corporations and/or individual tax returns

●If not a certified DBE, please provide documentation that you are self-certified as a small business (please contact

Procurement Technical Assistance Center (PTAC) at 907-786-7258 if you require assistance on becoming a self- certified small business)

At time of award send required documentation to:

DOT&PF Civil Rights Office

Attn: Certification

PO Box 196900

Anchorage, Alaska 99519-690

Phone: (907) 269-0851

Fax: (907) 269-0847

A. SBE Directory Information

4.Contact Info.

Name of Firm		Contact Name
Telephone Number		Fax Number
Email Address		Company Website

Form 25D-6 (1/16)