224-22 Exhibit B-RFQ Licensed Tree Expert for Township Tree Inventory.pdf

TOWNSHIP OF WEST ORANGE Page | 18 STOCKHOLDER DISCLOSURE CERTIFICATION I certify that the list below contains the names and home addresses of all stockholders holding 10% or more of the issued and outstanding stock of the undersigned. ______ I certify that no one stockholder owns 10% or more of the issued and outstanding stock of the undersigned. _____ PLEASE CHECK TYPE OF BUSINESS ORGANIZATION: Partnership ____ Limited Partnership ____ Limited Liability Corp ____ Corporation ____ Sole Proprietorship ____ Limited Liability Partnership ___ Subchapter S Corp ____ PLEASE CHECK APPROPRIATE BOXES AND SIGN BELOW Name: _______________________________________________ Home Address: ________________________________________ _____________________________________________________ Stockholders Name: ________________________________________________ Home Address: _________________________________________ ______________________________________________________ Name_________________________________________________ Home Address: __________________________________________ _______________________________________________________ __________________________________ ______________________________________ Owner or Representative Signature Print Name & Title NOTORY PUBLIC Sworn before me thisday of ___________20_____.