City and County of San Francisco ContractorDevelopment Program (CCSF) Enrollment Form How did you hear about CCSF?(Required)Participant InformationCompany Name:(Required)Address:(Required) Address Line 2 Name of Owner:(Required) First Last Name of Manager: First Last Phone:(Required)Fax:Cell:Owner Email:(Required) Manager Email: Company InformationTrade Specialty:(Required)CSLB No:CSLB Class:Type of Entity:(Required)Select OneCorporationPartnershipSole ProprietorOtherIf Other, please explain:(Required)Date Business Established:(Required) MM slash DD slash YYYY Annual Business Volume ($):(Required)Business RelationshipsDo you currently have bonding?(Required) Yes No Broker:(Required)Surety:(Required)Bank:(Required)Current Bond Capacity: Single ($)(Required)Aggregate ($)(Required)Credit Line Available ($):(Required)In the past three (3) years, I have BID on Public Works projects as a:(Required)Select OnePrimeSubBothNoneIn the past three (3) years, I have been AWARDED on Public Works projects as a:(Required)Select OnePrimeSubBothNoneCertification & EthnicityCertification Status:(Required)ActivePendingNoneIs your firm signatory to a union?(Required) Yes No Which Union?(Required)Certified As:(Required) Select All SBE DBE WBE MBE DVBF EBE SB-PW SB-MB SLB CBE SE LSBE LBE LGTBQ+ None Other Certified As other:(Required)Certified With:(Required) Select All Contract Monitoring Division State of California (DGS) California Unified Certification Program San Francisco Public Utilities Commission Ethnicity:(Required)Select OneAfrican-AmericanHispanic AmericanAsian-Pacific AmericanSubcontinent Asian-Pacific AmericanNative AmericanCaucasianOtherIf Other is selected, please state ethnicity/ethnicities:(Required)AuthorizationI/WE AUTHORIZE AND CONSENT TO MERRIWETHER AND WILLIAMS INSURANCE SERVICES, INC. (MWIS), AS BOND ASSISTANCE PROGRAM ADMINISTRATORS, AND/OR SURETY/BANK OBTAINING INFORMATION FROM THIRD PARTIES, INCLUDING BUT NOT LIMITED TO, CREDITORS, BROKERS, SURETIES, INSURERS, BANKS, OR ANY INDIVIDUAL(S) OR INDIVIDUAL REPRESENTATIVE(S) OF ANY FIRM(S), ENTITY (IES) OR ORGANIZATION(S) LISTED IN THE DOCUMENTS SUBMITTED BY ME/US OR FOR ANY OTHER PURPOSE RELATED TO THE EVALUATION OF MY/OUR QUALIFICATIONS. I/WE RECOGNIZE THAT TO ENSURE THE EFFECTIVENESS OF THE ENROLLMENT PROCESS, SUCH INDIVIDUALS MUST BE ABLE TO SPEAK FRANKLY AND OPENLY. ACCORDINGLY, I/WE HEREBY FULLY AND UNCONDITIONALLY RELEASE AND DISCHARGE SUCH THIRD-PARTY INDIVIDUALS AND THE FIRMS, ENTITIES AND ORGANIZATIONS THEY REPRESENT, FROM ANY CLAIM OR LIABILITY RELATING TO INFORMATION PROVIDED IN CONNECTION WITH THE PROCESSING, INVESTIGATION, AND EVALUATION OF OUR APPLICATION OR ENROLLMENT DOCUMENTATION.Signature of Applicant:(Required)Date:(Required) MM slash DD slash YYYY Δ
