PLEASE PRINT LEGIBLY OR TYPE. Name: Student M # Fraternity Name_ Last First MI This is a billing agreement between the student noted above and Middle Tennessee State University for housing on Greek Row for the period of: _Fall 2017 Rent Amount to be charged: _Fall 2017 CAM Fees Amount to be charged: Fall 2017 Laundry Fees Amount to be charged: Room Number Assigned in House: _ I have read and agree to this housing agreement and to the foregoing Terms and Conditions, and I agree to abide by all University and Fraternity regulations. I also understand that this agreement is null and void if not attached to an executed housing contract between myself and the Lessee in whose house I plan to reside. I UNDERSTAND THAT I AM SIGNING A LEGALLY BINDING AGREEMENT THROUGH WHICH MY FRATERNITY HOUSE RENT AND CAM FEES (AND IF APPLICABLE OTHER CHARGES) WILL APPEAR ON MY MTSU BILLING STATEMENT, AND THAT FAILURE TO MEET MY FINANCIAL OBLIGATIONS COULD RESULT IN HOLDS BEING PLACED ON MY REGISTRATION, GRADUATION AND/OR OFFICIAL TRANSCRIPT. Student Signature: Date: House Corporation President Signature: Date: _
PLEASE PRINT LEGIBLY OR TYPE. Type of contract you are applying for (check all that may apply): Residential Weatherization Construction: minor repairs, batt insulation, blown insulation, window and door repair and weather-stripping, air sealing, caulking, replacement of windows and doors, minor or incidental structural repairs, duct sealing and/or repair and/or replacement. HVAC Mechanical: furnace/cooling system major overhaul, repair or replacement; water heater repair or replacement, etc. Other: Business Name: Owner/Representative: Business Address: Number Street City Zip Code Mailing Address: Number Street City Zip Code Area Code/Phone Numbers: Office Fax Mobile Email Address: Federal I.D. #: If not incorporated, Social Security #: Year firm was established: License Information: Residential Builders/Maintenance & Alteration License # Expiration Date Mechanical Contractor's License # Expiration Date Other (Specify) License # Expiration Date Have you ever participated in the Weatherization Assistance Program before? Yes No If yes, when? , and where? Have you or any of your employees received a certificate for having attended a Lead Safe Work Practice Training? Yes No If yes, please provide copy of certificate. Have you or any of your employees attended a DHS-sponsored Indoor Air Quality Training? Yes No If yes, please provide documentation of attendance. Have you or any of your employees received a certificate for having completed the LRRP requirements? Yes No If yes, please provide copy of certificate. Have you or any of your employees received a certificate for having completed the MIOSHA requirements? Yes No If yes, please provide copy of certificate Areas of Expertise: Please check the type of work you are qualified/licensed to perform. Check if the work is performed by company employees (CO) or sub-contractors (SUB), and indicate the years of experience you had in that area of work. Type of Work CO SUB # of Yrs of Exp General carpentry Roofing Attic Insulation Sidewall Insulation (dense pack/blown in) Bypass/Air Sealing Door/window replacement IAQ Certification Glass Replacement and Glazing Drywall General Mobile Home Repairs Heating & Ventilation – Repair and Replacement Plumbing Electrical Asbestos Abatement Lead Abatement Blower Door Experience Please provide an estimate of the number of Weatherization jobs your company could complete per week, if awarded a contract: How many employees do you employ full-time? part-time? Please list all education and training that you have ha...
