City / Town Prequalification Form
Check One Below:
Chapter 90 Funds
Municipality Funds
Name of City/Town:_________________________________________________________________
Description of Work: __________________________________________________________________
Class of Work: _______________________________________________________________________
(Please leave class of work blank this is to be determined by MassDOT)
Project Value: ________________________________________________________________________
Bid Opening Date: ____________________________________________________________________
Anticipated Date: _____________________________________________________________________
Anticipated Start Date: ________________________________________________________________
Anticipated End Date: _________________________________________________________________
Contact Person: _____________________________________________________________________
Telephone #: ________________________________________________________________________
Email: _____________________________________________________________________________
Required Attachments:
Legal Advertisement
Items List
Scope of Work
You may MAIL and/or EMAIL all information with this form to:
MassDOT, Highway Division
Prequalification Office
10 Park Plaza, Room 3620
Boston, MA 02116
EMAIL: PREQUAL.R109@STATE.MA.US
PHONE: (857) 368 - 8660
In accordance with M.G.L. c. 81, §8B, any Contractor or Prospective Bidder proposing to bid on
any work, excepting the construction, reconstruction, repair, or alteration of buildings, to be
awarded by the Department of Conservation and Recreation, aggregating $50,000 or more, must be
prequalified by the Highway Division of the Massachusetts Department of Transportation pursuant
to 720 CMR 5.01, et seq. (cite 320 CMR 17.00, 17.02) in the specified class of work with a single
contract limit greater than or equal to the advertised project value.
NOTIFY MASSDOT of any changes of contact information, bid dates, project value(s), addendums, etc.
Rev. 06/11/13
MUNICIPALITY CHECKLIST
GENERAL INSTRUCTIONS
To receive the assignment of a Prequalification Class of Work and subsequent lists of prequalified contractors, a
Chapter 90 Form must be completed in its entirety and received by the MassDOT Prequalification Office prior
to your earliest anticipated bid opening date.
KEEP THIS DOCUMENT FOR YOUR RECORDS.
BEFORE MOVING ON TO COMPLETE DOCUMENTATION, PLEASE PRINT CHAPTER 90
CHECKLIST TO USE WHEN FILLING OUT YOUR DOCUMENTATION TO ENSURE
COMPLETION IN ITS ENTIRETY.
 City / Town Prequalification Form
 Item List
 Scope of Work
 Legal Advertisement or Invitation to Bid Notification
 Chapter 90 Project Request Form (If Applicable)
 City/Town to Notify The Prequalification Department of Successful Contract
Awardee(s)
Provide Contract Value and the Length of Contract
Contact the Prequalification Department to Confirm at Notice To Proceed
(NTP) to Confirm the Awarded Contractor(s) Certification is Current and Request
the Contractor(s) Certification Expiration Date. (Multi-Year contracts only)
Rev. 06/11/13