sample the projects cover the scope of work of the
TRANSCRIPT
Project Verification FormMail To: Registrar of Contractors P.O. Box 6688Phoenix, AZ 85005-6688
Visit our website at: www.azroc.gov
Part 1: Information to be Completed by the Qualifying Party Qualifying Party’s Name (Last, First, Middle) Project Name
Project Address City State Zip
Date Project Began Date Project Ended Project Size (e.g. building size, lot size) Project Contract Price
Instructions for Person Providing Verification: 1. Complete the information requested below (including having your signature notarized).2. Return this Project Verification Form to the qualifying party.
Part 2: Information to be Completed by Person Providing Verification Verifier’s Name (Last, First, Middle)
Verifier’s Mailing Address City State Zip
Verifier’s Phone Number Verifier’s Email Verifier’s Fax
Verifier’s Role for this Project
Journeyman Superintendent Contractor (list license # and classification)
Foreman Property Owner Other (please describe):
Qualifying Party’s Duties on this Project
I certify that I have direct knowledge of this qualifying party’s work covering the time period outlined above. I certify that I have reviewed the entire contents of this verification form and the information provided is true and accurate. I understand that providing false information is a violation of the Arizona Criminal Code in Arizona Revised Statutes, Title 13, Chapter 27. Printed Name Signature Date
Subscribed and sworn to me on the _____ day of ______________________, 20___ [Notary Seal]
__________________________________________________________________________
Notary Public
RCL200S1 1/15
27 March 15
John Notary
First Verifier
The number of project verifications submitted meets the guidelines in the instructions; for this classification 5 new and 5 maintenance projects.
The projects span the number of years’ experience required to qualify for the license; for this classification 4 years.
The projects cover the scope of work of the classification.SAMPLERoc, Alvin, Simon Parking garage
AZPhoenix123 N. First Street 85007-0001
1/1/2008 11/30/2008 200,000 sq. ft 1,200,000.00
Verifier, First, Project
9876 Verifier St. Phoenix AZ 85007-0001
(602) 111-1111 [email protected] (602) 222-2222
ROC # 001122 A-General Engineering
Alvin Roc was the project manager for this project. The project included cassion drilled shaft footings,
concrete piers, cast in place columns, slab on grade, slab on precast, topping slabs, and other sitework.
Alvin scheduled the subcontractors and employees and made sure the project finished on time and
within budget.
First Verifier 3/27/2015
Project Verification FormMail To: Registrar of Contractors P.O. Box 6688Phoenix, AZ 85005-6688
Visit our website at: www.azroc.gov
Part 1: Information to be Completed by the Qualifying Party Qualifying Party’s Name (Last, First, Middle) Project Name
Project Address City State Zip
Date Project Began Date Project Ended Project Size (e.g. building size, lot size) Project Contract Price
Instructions for Person Providing Verification: 1. Complete the information requested below (including having your signature notarized).2. Return this Project Verification Form to the qualifying party.
Part 2: Information to be Completed by Person Providing Verification Verifier’s Name (Last, First, Middle)
Verifier’s Mailing Address City State Zip
Verifier’s Phone Number Verifier’s Email Verifier’s Fax
Verifier’s Role for this Project
Journeyman Superintendent Contractor (list license # and classification)
Foreman Property Owner Other (please describe):
Qualifying Party’s Duties on this Project
I certify that I have direct knowledge of this qualifying party’s work covering the time period outlined above. I certify that I have reviewed the entire contents of this verification form and the information provided is true and accurate. I understand that providing false information is a violation of the Arizona Criminal Code in Arizona Revised Statutes, Title 13, Chapter 27. Printed Name Signature Date
Subscribed and sworn to me on the _____ day of ______________________, 20___ [Notary Seal]
__________________________________________________________________________
Notary Public
RCL200S1 1/15
27 March 15
John Notary
Second Verifier
Roc, Alvin, Simon Public Park
AZPhoenix123 N. First Street 85007-0001
12/1/2008 10/31/2009 500,000 sq. ft 600,000.00
Verifier, Second, Project
9876 Verifier St. Phoenix AZ 85007-0001
(602) 111-1111 [email protected] (602) 222-2222
City Engineer
Alvin Roc was the project manager for this project. The project included grading, sitework, laying water
and electrical lines, walkways, fences, benches, unenclosed ramadas, and restrooms.
Second Verifier 3/27/2015
SAMPLE
Project Verification FormMail To: Registrar of Contractors P.O. Box 6688Phoenix, AZ 85005-6688
Visit our website at: www.azroc.gov
Part 1: Information to be Completed by the Qualifying Party Qualifying Party’s Name (Last, First, Middle) Project Name
Project Address City State Zip
Date Project Began Date Project Ended Project Size (e.g. building size, lot size) Project Contract Price
Instructions for Person Providing Verification: 1. Complete the information requested below (including having your signature notarized).2. Return this Project Verification Form to the qualifying party.
Part 2: Information to be Completed by Person Providing Verification Verifier’s Name (Last, First, Middle)
Verifier’s Mailing Address City State Zip
Verifier’s Phone Number Verifier’s Email Verifier’s Fax
Verifier’s Role for this Project
Journeyman Superintendent Contractor (list license # and classification)
Foreman Property Owner Other (please describe):
Qualifying Party’s Duties on this Project
I certify that I have direct knowledge of this qualifying party’s work covering the time period outlined above. I certify that I have reviewed the entire contents of this verification form and the information provided is true and accurate. I understand that providing false information is a violation of the Arizona Criminal Code in Arizona Revised Statutes, Title 13, Chapter 27. Printed Name Signature Date
Subscribed and sworn to me on the _____ day of ______________________, 20___ [Notary Seal]
__________________________________________________________________________
Notary Public
RCL200S1 1/15
27 March 15
John Notary
Third Verifier
Roc, Alvin, Simon Public Road
AZPhoenix123 N. First Street 85007-0001
11/1/2009 12/31/2012 20 miles 20,000,000.00
Verifier, Third Project
9876 Verifier St. Phoenix AZ 85007-0001
(602) 111-1111 [email protected] (602) 222-2222
ROC 123456 A-General Engineering
Replace water, sewer, and storm drains; earthwork, grading, and concrete paving
Third Verifier 3/27/2015
SAMPLE
Project Verification FormMail To: Registrar of Contractors P.O. Box 6688Phoenix, AZ 85005-6688
Visit our website at: www.azroc.gov
Part 1: Information to be Completed by the Qualifying Party Qualifying Party’s Name (Last, First, Middle) Project Name
Project Address City State Zip
Date Project Began Date Project Ended Project Size (e.g. building size, lot size) Project Contract Price
Instructions for Person Providing Verification: 1. Complete the information requested below (including having your signature notarized).2. Return this Project Verification Form to the qualifying party.
Part 2: Information to be Completed by Person Providing Verification Verifier’s Name (Last, First, Middle)
Verifier’s Mailing Address City State Zip
Verifier’s Phone Number Verifier’s Email Verifier’s Fax
Verifier’s Role for this Project
Journeyman Superintendent Contractor (list license # and classification)
Foreman Property Owner Other (please describe):
Qualifying Party’s Duties on this Project
I certify that I have direct knowledge of this qualifying party’s work covering the time period outlined above. I certify that I have reviewed the entire contents of this verification form and the information provided is true and accurate. I understand that providing false information is a violation of the Arizona Criminal Code in Arizona Revised Statutes, Title 13, Chapter 27. Printed Name Signature Date
Subscribed and sworn to me on the _____ day of ______________________, 20___ [Notary Seal]
__________________________________________________________________________
Notary Public
RCL200S1 1/15
27 March 15
John Notary
Fourth Verifier
Roc, Alvin, Simon Bridge/Overpass
AZPhoenix123 N. First Street 85007-0001
12/1/2009 3/31/2010 200 feet across 200,000.00
Verifier, Fourth Project
9876 Verifier St. Phoenix AZ 85007-0001
(602) 111-1111 [email protected] (602) 222-2222
ROC #456789 A-General Engineering
Alvin Roc was the project manager for this project. The project included replacing a bridge consistent
with AASHTO/ADOT standards. The new bridge had vehicular traffic running below and required custom
steel mesh panels to provide pedestrial safety. The reconstruction required excavating and replacing the
concrete foundation. Alvin also engineered the shop drawings of the bridge.
Fourth Verifier 3/27/2015
SAMPLE
Project Verification FormMail To: Registrar of Contractors P.O. Box 6688Phoenix, AZ 85005-6688
Visit our website at: www.azroc.gov
Part 1: Information to be Completed by the Qualifying Party Qualifying Party’s Name (Last, First, Middle) Project Name
Project Address City State Zip
Date Project Began Date Project Ended Project Size (e.g. building size, lot size) Project Contract Price
Instructions for Person Providing Verification: 1. Complete the information requested below (including having your signature notarized).2. Return this Project Verification Form to the qualifying party.
Part 2: Information to be Completed by Person Providing Verification Verifier’s Name (Last, First, Middle)
Verifier’s Mailing Address City State Zip
Verifier’s Phone Number Verifier’s Email Verifier’s Fax
Verifier’s Role for this Project
Journeyman Superintendent Contractor (list license # and classification)
Foreman Property Owner Other (please describe):
Qualifying Party’s Duties on this Project
I certify that I have direct knowledge of this qualifying party’s work covering the time period outlined above. I certify that I have reviewed the entire contents of this verification form and the information provided is true and accurate. I understand that providing false information is a violation of the Arizona Criminal Code in Arizona Revised Statutes, Title 13, Chapter 27. Printed Name Signature Date
Subscribed and sworn to me on the _____ day of ______________________, 20___ [Notary Seal]
__________________________________________________________________________
Notary Public
RCL200S1 1/15
27 March 15
John Notary
Fifth Verifier
Roc, Alvin, Simon Fast Food Site Preparation
AZPhoenix123 N. First Street 85007-0001
1/1/2010 4/30/2010 3000 sq. ft. 110,000.00
Verifier, Fifth Project
9876 Verifier St. Phoenix AZ 85007-0001
(602) 111-1111 [email protected] (602) 222-2222
Mr. Fry Hamburger, restaurant owner
Site preparation for a fast food store. The project included site concrete; building slab of 4" concrete with
#3 rebar; parking curbs, drivethrough curbs, trash enclosure and footings, sidewalks, ADA ramp, light pole
bases, and security lighting in parking lot.
Fifth Verifier 3/27/2015
SAMPLE
Project Verification FormMail To: Registrar of Contractors P.O. Box 6688Phoenix, AZ 85005-6688
Visit our website at: www.azroc.gov
Part 1: Information to be Completed by the Qualifying Party Qualifying Party’s Name (Last, First, Middle) Project Name
Project Address City State Zip
Date Project Began Date Project Ended Project Size (e.g. building size, lot size) Project Contract Price
Instructions for Person Providing Verification: 1. Complete the information requested below (including having your signature notarized).2. Return this Project Verification Form to the qualifying party.
Part 2: Information to be Completed by Person Providing Verification Verifier’s Name (Last, First, Middle)
Verifier’s Mailing Address City State Zip
Verifier’s Phone Number Verifier’s Email Verifier’s Fax
Verifier’s Role for this Project
Journeyman Superintendent Contractor (list license # and classification)
Foreman Property Owner Other (please describe):
Qualifying Party’s Duties on this Project
I certify that I have direct knowledge of this qualifying party’s work covering the time period outlined above. I certify that I have reviewed the entire contents of this verification form and the information provided is true and accurate. I understand that providing false information is a violation of the Arizona Criminal Code in Arizona Revised Statutes, Title 13, Chapter 27. Printed Name Signature Date
Subscribed and sworn to me on the _____ day of ______________________, 20___ [Notary Seal]
__________________________________________________________________________
Notary Public
RCL200S1 1/15
27 March 15
John Notary
Sixth Verifier
Roc, Alvin, Simon Underground revitalization
AZPhoenix123 N. First Street 85007-0001
7/1/2010 5/31/2011 city block 2,000,000.00
Verifier, Sixth Project
9876 Verifier St. Phoenix AZ 85007-0001
(602) 111-1111 [email protected] (602) 222-2222
ROC #123456 A-General Engineering
replace water, sewer, and storm drains; earthwork, grading, and concrete paving
Sixth Verifier 3/27/2015
SAMPLE
Project Verification FormMail To: Registrar of Contractors P.O. Box 6688Phoenix, AZ 85005-6688
Visit our website at: www.azroc.gov
Part 1: Information to be Completed by the Qualifying Party Qualifying Party’s Name (Last, First, Middle) Project Name
Project Address City State Zip
Date Project Began Date Project Ended Project Size (e.g. building size, lot size) Project Contract Price
Instructions for Person Providing Verification: 1. Complete the information requested below (including having your signature notarized).2. Return this Project Verification Form to the qualifying party.
Part 2: Information to be Completed by Person Providing Verification Verifier’s Name (Last, First, Middle)
Verifier’s Mailing Address City State Zip
Verifier’s Phone Number Verifier’s Email Verifier’s Fax
Verifier’s Role for this Project
Journeyman Superintendent Contractor (list license # and classification)
Foreman Property Owner Other (please describe):
Qualifying Party’s Duties on this Project
I certify that I have direct knowledge of this qualifying party’s work covering the time period outlined above. I certify that I have reviewed the entire contents of this verification form and the information provided is true and accurate. I understand that providing false information is a violation of the Arizona Criminal Code in Arizona Revised Statutes, Title 13, Chapter 27. Printed Name Signature Date
Subscribed and sworn to me on the _____ day of ______________________, 20___ [Notary Seal]
__________________________________________________________________________
Notary Public
RCL200S1 1/15
27 March 15
John Notary
Seventh Verifier
Roc, Alvin, Simon Roadway project
AZPhoenix123 N. First Street 85007-0001
10/1/2012 1/31/2015 7 city blocks 3,000,000.00
Verifier, Seventh Project
9876 Verifier St. Phoenix AZ 85007-0001
(602) 111-1111 [email protected] (602) 222-2222
Mr. A.D.O.T. Supervisor
new traffic signals, street lights, concrete curb and gutter, underground water drainage for storm water,
earthwork, paving, striping and signage
Seventh Verifier 3/27/2015
SAMPLE
Project Verification FormMail To: Registrar of Contractors P.O. Box 6688Phoenix, AZ 85005-6688
Visit our website at: www.azroc.gov
Part 1: Information to be Completed by the Qualifying Party Qualifying Party’s Name (Last, First, Middle) Project Name
Project Address City State Zip
Date Project Began Date Project Ended Project Size (e.g. building size, lot size) Project Contract Price
Instructions for Person Providing Verification: 1. Complete the information requested below (including having your signature notarized).2. Return this Project Verification Form to the qualifying party.
Part 2: Information to be Completed by Person Providing Verification Verifier’s Name (Last, First, Middle)
Verifier’s Mailing Address City State Zip
Verifier’s Phone Number Verifier’s Email Verifier’s Fax
Verifier’s Role for this Project
Journeyman Superintendent Contractor (list license # and classification)
Foreman Property Owner Other (please describe):
Qualifying Party’s Duties on this Project
I certify that I have direct knowledge of this qualifying party’s work covering the time period outlined above. I certify that I have reviewed the entire contents of this verification form and the information provided is true and accurate. I understand that providing false information is a violation of the Arizona Criminal Code in Arizona Revised Statutes, Title 13, Chapter 27. Printed Name Signature Date
Subscribed and sworn to me on the _____ day of ______________________, 20___ [Notary Seal]
__________________________________________________________________________
Notary Public
RCL200S1 1/15
27 March 15
John Notary
Eighth Verifier
Roc, Alvin, Simon Commercial Sitework
AZPhoenix123 N. First Street 85007-0001
10/1/2011 12/31/2014 10 acres 1,000,000.00
Verifier, Eighth Project
9876 Verifier St. Phoenix AZ 85007-0001
(602) 111-1111 [email protected] (602) 222-2222
ROC#000000
clear and grub 10 acres of land, excavate, grade, add 22,000 cubic yards of fill, install 15,000 fine grade
pad, landscape, install utilities, add 7,000 of aggregate base, pave 3,000 tons of parking lot, add curbing
and sidewalk, and strip parking spaces
Eighth Verifier 3/27/2015
SAMPLE
Project Verification FormMail To: Registrar of Contractors P.O. Box 6688Phoenix, AZ 85005-6688
Visit our website at: www.azroc.gov
Part 1: Information to be Completed by the Qualifying Party Qualifying Party’s Name (Last, First, Middle) Project Name
Project Address City State Zip
Date Project Began Date Project Ended Project Size (e.g. building size, lot size) Project Contract Price
Instructions for Person Providing Verification: 1. Complete the information requested below (including having your signature notarized).2. Return this Project Verification Form to the qualifying party.
Part 2: Information to be Completed by Person Providing Verification Verifier’s Name (Last, First, Middle)
Verifier’s Mailing Address City State Zip
Verifier’s Phone Number Verifier’s Email Verifier’s Fax
Verifier’s Role for this Project
Journeyman Superintendent Contractor (list license # and classification)
Foreman Property Owner Other (please describe):
Qualifying Party’s Duties on this Project
I certify that I have direct knowledge of this qualifying party’s work covering the time period outlined above. I certify that I have reviewed the entire contents of this verification form and the information provided is true and accurate. I understand that providing false information is a violation of the Arizona Criminal Code in Arizona Revised Statutes, Title 13, Chapter 27. Printed Name Signature Date
Subscribed and sworn to me on the _____ day of ______________________, 20___ [Notary Seal]
__________________________________________________________________________
Notary Public
RCL200S1 1/15
27 March 15
John Notary
Ninth Verifier
Roc, Alvin, Simon New Wastewater Treatment Plant
AZPhoenix123 N. First Street 85007-0001
10/1/2011 12/31/2013 50,000 sq. ft. 10,000,000.00
Verifier, Ninth Project
9876 Verifier St. Phoenix AZ 85007-0001
(602) 111-1111 [email protected] (602) 222-2222
City Engineer
Alvin ROC was the superintendent on this city project to construct a new wastewater treatment facility;
including sitework, utilities, structural work, water filtration systems, pumps, piping, storage tanks, and
necessary structures
Ninth Verifier 3/27/2015
SAMPLE
Project Verification FormMail To: Registrar of Contractors P.O. Box 6688Phoenix, AZ 85005-6688
Visit our website at: www.azroc.gov
Part 1: Information to be Completed by the Qualifying Party Qualifying Party’s Name (Last, First, Middle) Project Name
Project Address City State Zip
Date Project Began Date Project Ended Project Size (e.g. building size, lot size) Project Contract Price
Instructions for Person Providing Verification: 1. Complete the information requested below (including having your signature notarized).2. Return this Project Verification Form to the qualifying party.
Part 2: Information to be Completed by Person Providing Verification Verifier’s Name (Last, First, Middle)
Verifier’s Mailing Address City State Zip
Verifier’s Phone Number Verifier’s Email Verifier’s Fax
Verifier’s Role for this Project
Journeyman Superintendent Contractor (list license # and classification)
Foreman Property Owner Other (please describe):
Qualifying Party’s Duties on this Project
I certify that I have direct knowledge of this qualifying party’s work covering the time period outlined above. I certify that I have reviewed the entire contents of this verification form and the information provided is true and accurate. I understand that providing false information is a violation of the Arizona Criminal Code in Arizona Revised Statutes, Title 13, Chapter 27. Printed Name Signature Date
Subscribed and sworn to me on the _____ day of ______________________, 20___ [Notary Seal]
__________________________________________________________________________
Notary Public
RCL200S1 1/15
27 March 15
John Notary
Tenth Verifier
Roc, Alvin, Simon Street Maintenance Project
AZPhoenix123 N. First Street 85007-0001
6/1/2014 1/31/2015 15 miles 500,000.00
Verifier, Tenth Project
9876 Verifier St. Phoenix AZ 85007-0001
(602) 111-1111 [email protected] (602) 222-2222
City Engineer
grading and repaving city street
Tenth Verifier 3/27/2015
SAMPLE