Subcontractor services letter for DEP, February 2012

NYC 9/11 Public Portal Document

CITY OF NEW YORK SUBCONTRACTOR PROFILE FORM

TO BE COMPLETED BY SUBCONTRACTOR

INSTRUCTIONS TO PRIME CONTRACTOR

A Subcontractor Profile Form must be completed by EACH subcontractor that will perform on the contract. Make additional copies of this form as needed.

PRIME CONTRACTOR NAME _X_._EIN _ _._._._._ SSN Jenny/BAC Killam, A Joint Venture _ _ _ __P11

DEP CONTRACT #EE-GEO-02 & EE-GEO-03 REGISTRATION #82620060020284

SUBCONTRACTOR NAME EIN X SSN

Galyn Rippentrop ._._._._._.Pii _._._._._.

SUBCONTRACTOR BUSINESS ADDRESS

P.O. Box 89321 Sioux Falls, SD 57109

Number Street Borough/City State Zip

SUBCONTRACTOR BILLING ADDRESS (IF DIFFERENT FROM ABOVE)

Number Street Borough/City State Zip

SUBCONTRACTOR TELEPHONE (812) 431-8364

SUBCONTRACTOR AMOUNT $15,000

DESCRIPTION OF SUBCONTRACT AND LOCATION providing input to Reviewing information, travel to Technical Review Committee (TRC) meeting(s), participation in the TRC, and report prepared by others

FORM 6,1, %~" COMPLETED Name (PRI ) of Subc n actor's Repres ntative Title BY o

Signature1 ' Date

MOCS Subcontractor Approval Form (Sept. 2010)

NYC-WTC 000159325