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<br />,I <br /> <br />,e <br /> <br />CONTRACTOR'S STATEMENT <br /> <br />Date of Contractor's Statement <br /> <br />,"".. <br /> <br />, 19 <br /> <br />. \ <br />\ \ <br />) , <br /> <br />Submitted to: <br /> <br />Name <br /> <br />Address <br /> <br />Telephone: ( ) <br /> <br />Submitted by: <br /> <br />Legal name under which you wish to qualify <br /> <br />() Individual <br />() Partnership <br />() Joint Venture <br />() Corporation <br />() Other <br /> <br />Post Office Box <br /> <br />Zip Code <br /> <br />Street Address <br /> <br />Zip Code <br /> <br />City/State <br /> <br />Telephone <br /> <br />( <br /> <br />) <br /> <br />Texas Vendor Identification No. <br /> <br />Federal Employer's Identification No. <br /> <br />-3- <br />