18-10 Contract

STATEMENT OF INDIVIDUALIS) OWNING 10% OR MORE OF STOCK OR INTEREST IN THE BIDDER’S BUSINESS ENTITY In accordance with N.J.S.A, $2:25-24.) et 5eq., NO Corporation, partnership, limited partnership, limited liabili ty corporation, limited liability partnership, Subchapter $ corporation or sole proprietorship, shall be awarded a contract, unless prior to the receipt of the bid or accompanying the bid of the corporation, partnership, limited partnership, limited liability corporation, limited liability partnership, Subchapter $ corporation or sole proprietorship, there is submitted to the County, a statement setting forth the names and addresses of all stockholders who own ten percent (10%) or more of the stock, of any class or all individual partners who own a ten percent (10%) or greater interest in the corporation, partnership, limited partnership, limited liability corporation, limited liability partnershi , Subchapter $ corporation or sole Proprietorship. If one or more such stockholder or partner is itself 2 corporation or partnership, the stockholders holding ten percent (10%) or more of that Corporation's stock, or the individual partners owning len percent (10%) or greater interest in that partnership, as the case may be, shall also be listed. The disclosure shall be continued until names and addresses of every noncorporate stockholder and individual partner, exceeding the ten percent (10%) ownership criteria established in this act has been listed. Township of West Orange 01/07/10 Legal Name of Vendor Date 66 Main Street ; West Orange NJ, 07052 Street Address Cit State Zip Code 973-325-4124 / 973-325-4005 | heatthdepttivestoFBh8.org Telephone # Pax # e-mail address N/A CHECK TYPE OF BUSINESS ENTITY: Date Where Incorporated Incorporated Corporation Limited Partnership Limited Liability Corporation Limited Liability Partnership Subchapter S Corporation Sole Proprietorship Partnership Listed below are the names and address of all stockholders or individuals who own ten (10) percent or more of its stock of any class(es), or who own ten (10) percent or greater interest therein, N/A Name Address Name Address Name Address Ifmore space is required, continue listing on a separate page and include with bid submittal, If no stockholder or partner owns ten percent (10%) or more of the business submitting the bid, please sign and date this form. 1 certify

ue listing on a separate page and include with bid submittal, If no stockholder or partner owns ten percent (10%) or more of the business submitting the bid, please sign and date this form. 1 certify that no stockholder or partner owns ten percent (10%) or more of the business submitting this bid: J 01/07/10 uthorized Representative Date O COMPLETE THIS FORM OR SIGN THE ABOVE STATEMENT BY A DULY AUTHORIZED COMPANY OFFICIAL WILL RESULT IN REJECTION OF THIS PROPOSAL.