Criteria Developer Selection Form - Design-Build Board

State of West Virginia Design-Build Procurement Act West Virginia Code, §5-22A-2 and Legislative Rules, 148-CSR-11 Require the Performance Criteria Developer be selected in accordance with West Virginia Code §5G-1-1

Criteria Developer Selection Form Please forward your completed form to: Design-Build Board c/o West Virginia Department of Administration 1900 Kanawha Boulevard, East Room E-119 Charleston, WV 25305

PLEASE TYPE OR PRINT CLEARLY ALL INFORMATION

Name of Agency: Address: City/State/Zip: Contact Person: Telephone Number:

Fax Number:

E-Mail Address:

Project Name and Date Approved by Board:

(Please complete the following:)

Provide a copy of the advertisement soliciting a Performance Criteria Developer: Newspaper & other publication names: Date of advertisement:

Please identify the individuals/firms that were short listed:

Please identify the individuals/firms interviewed and the date of the interview:

Please identify the name, address and phone number of the individual/firm selected to be the Performance Criteria Developer on this project:

Please provide the West Virginia license number for the Performance Criteria Developer as well as a copy of the seal. West Virginia License #

(Copy of Seal must be provided)

As the authorized agent of the Agency named above, I do hereby solemnly swear that the information contained in this “Criteria Developer Selection Form” is true and complete to the best of my knowledge.

Name of Authorized Representative

Dated this

day of

Title

, 20

.