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Gilbane Building Company 16 <br /> Prequalification Form for First-Tier Subcontractors under CM at Risk <br /> Orange County Crisis Diversion Facility <br /> SECTION 4. Signature <br /> By signing this document,you are acknowledging that all answers are true to the best of your knowledge. <br /> Any answers found to be falsified will bar you from being prequalified on this project. <br /> Company Name: <br /> Dated this day of: <br /> Submitted by: (signature) <br /> (print) <br /> (title) <br /> (phone) <br /> (email) <br /> Notary Certification: <br /> North Carolina, County <br /> I, a Notary Public of the County and State aforesaid, certify that <br /> personally appeared before me this day and acknowledged the execution of the foregoing instrument. <br /> Witness my hand and official seal,this the _day of , 20_. <br /> Signature of Notary Public <br /> My commission expires , 20_ <br /> (Prequalification Ratings Matrix: If signature page fully executed give 1 point. If not, give 0 points.) <br /> SECTIONS. Prequalification Committee <br /> a. CM at Risk Prequalification Committee: <br /> o Project Executive—David Repnyek <br /> o Preconstruction Executive— Phill Herrell <br /> o Purchasing Director—Jennifer Quinn <br /> o Controller— Matt McGarry <br /> o Prequal Management—Daniel Buser <br /> b. Appeals Hearing Designee (Orange County Prequalification Official) <br /> Page 12 12 <br />