NYC 9/11 Public Portal Document
CITY OF NEW YORK
SUBCONTRACTOR PROFILE FORM
TO BE COMPLETED BY SUBCONTRACTOR
INSTRUCTIONS TO PRIME CONTRACTOR
subcontractor that will perform on the contract. Make
A Subcontractor Profile Form must be completed by EACH
additional copies of this form as needed.
PRIME CONTRACTOR NAME X EIN ❑ SSN
Jenny/BAC Killam, A Joint Venture ~...... .
DEP CONTRACT #EE-GEO-02 & EE-GEO-03 REGISTRATION #82620060020284
SUBCONTRACTOR NAME ❑EIN X SSN
Ian Michael Gowring
SUBCONTRACTOR BUSINESS ADDRESS
Auburn, CA 95603
8921 Memory Lane,
Borough/City State Zip
Number Street
SUBCONTRACTOR BILLING ADDRESS (IF DIFFERENT FROM ABOVE)
Borough/City State Zip
Number Street
SUBCONTRACTOR TELEPHONE (530)885-9055
SUBCONTRACTOR AMOUNT $12,000
DESCRIPTION OF SUBCONTRACT AND LOCATION
participation in the TRC, and providing input to
Reviewing information, travel to Technical Review Committee (TRC) meeting(s),
report prepared by others
FORM t kt4 M cHAt &oWR-t -
COMPLETED Name (PRINT) of Subcontractor's Representative Title
'
BY A
21-1- %-'
Signatur
MOCS Subcontractor Approval Form (Sept. 2010)
NYC-WTC 000159319
OCR can misread numbers and units. Confirm readings against the page image before using them.