Form CEM-1202A "Contractor Action Request - Change of Name/Address" - California

What Is Form CEM-1202A?

This is a legal form that was released by the California Department of Transportation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2015;
  • The latest edition provided by the California Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CEM-1202A by clicking the link below or browse more documents and templates provided by the California Department of Transportation.

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Download Form CEM-1202A "Contractor Action Request - Change of Name/Address" - California

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CONTRACTOR ACTION REQUEST - CHANGE OF NAME/ADDRESS
(Sections 1 - 4 only)
CEM-1202A (REV 09/2015)
Page 1 of 2
CONTRACT INFORMATION (As it currently appears)
Contract Number:
Contractor: (business name)
Contractor License #:
NAME CHANGE
New Business Name:
By checking this box, I confirm that contract bond and insurance documents issued with the new business name are attached.
MAILING ADDRESS CHANGE
Mailing Address:
Email:
City:
Phone:
State:
Zip Code:
Fax:
SUBMITTED BY
Contractor Representative's Name: (type or print)
Date:
Phone:
By checking this box, I confirm that a completed STD. 204 PAYEE DATA RECORD is attached.
- For Department Use Only -
Resident Engineer's Verification
Signature:
Date:
Resident Engineer's Name: (type or print)
Advantage CT Document Vendor Information Update
PRIOR to Advantage update (data entered by
AFTER Advantage update (data entered by
District Payments Coordinator)
District Payments Coordinator)
CT Document Identification Number
Vendor/Customer Identification Number
Vendor/Customer Address Identification Number
Advantage CT Document Vendor Information Updated By
CAS Updated By
District Payments Coordinator's Name: (type or print)
HQ Payments Coordinator's Name: (type or print)
Date:
Date:
Signature:
Signature:
For individuals with sensory disabilities, this document is available in alternate formats. For information, call (916) 445-1233,
ADA Notice
TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
Lock Data
CONTRACTOR ACTION REQUEST - CHANGE OF NAME/ADDRESS
(Sections 1 - 4 only)
CEM-1202A (REV 09/2015)
Page 1 of 2
CONTRACT INFORMATION (As it currently appears)
Contract Number:
Contractor: (business name)
Contractor License #:
NAME CHANGE
New Business Name:
By checking this box, I confirm that contract bond and insurance documents issued with the new business name are attached.
MAILING ADDRESS CHANGE
Mailing Address:
Email:
City:
Phone:
State:
Zip Code:
Fax:
SUBMITTED BY
Contractor Representative's Name: (type or print)
Date:
Phone:
By checking this box, I confirm that a completed STD. 204 PAYEE DATA RECORD is attached.
- For Department Use Only -
Resident Engineer's Verification
Signature:
Date:
Resident Engineer's Name: (type or print)
Advantage CT Document Vendor Information Update
PRIOR to Advantage update (data entered by
AFTER Advantage update (data entered by
District Payments Coordinator)
District Payments Coordinator)
CT Document Identification Number
Vendor/Customer Identification Number
Vendor/Customer Address Identification Number
Advantage CT Document Vendor Information Updated By
CAS Updated By
District Payments Coordinator's Name: (type or print)
HQ Payments Coordinator's Name: (type or print)
Date:
Date:
Signature:
Signature:
For individuals with sensory disabilities, this document is available in alternate formats. For information, call (916) 445-1233,
ADA Notice
TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
CONTRACTOR ACTION REQUEST - CHANGE OF NAME/ADDRESS
CEM-1202A (REV 09/2015)
Page 2 of 2
GENERAL INSTRUCTIONS
1. This form and form STD. 204 Payee Data Record are required when requesting a change in contractor's business name or mailing address.
2. If name or address change, also include change to contractor's license number, use form CEM-1203 instead of form CEM-1202A.
Instructions to the CONTRACTOR
3. Make a separate request per contract.
4. For name change only, complete Sections 1, 2, and 4.
5. For mailing address change only, complete Sections 1, 3, and 4.
6. For name and mailing address change, complete Sections 1, 2, 3, and 4.
7. Include as attachments performance and payment bonds; and insurance certificates and policies issued with the new business name. Also
include as an attachment proof from the California Contractors State License Board (CSLB) that your application for contractor's change in
business name is approved by the CSLB.
8. Submit completed form CEM-1202A and form STD. 204 to the resident engineer (do not complete Section 6 of form STD. 204). Prompt and
correct requests will prevent delay in processing payments.
Instructions to the RESIDENT ENGINEER
9. VERIFY form STD. 204 is attached to submitted form CEM-1202A.
10. REVIEW submittal for completeness and accuracy.
11. VERIFY business name and mailing address in form STD. 204 matches information in form CEM-1202A.
12. VERIFY business name in STD. 204 matches business name in payment and performance bonds; and insurance policies and certificates.
13. For business name change, VERIFY contractor's license with the
Contractors State License Board
includes the new business name.
14. VERIFY contractor's license number with
Contractors State License Board
is the same as listed in the contract documents. If license
number has changed, direct contractor to submit form CEM-1203.
15. Forward reviewed submittal to District Payments Coordinator.
16. For request of change to business name and for validation and approval of insurance policies and contracts bonds email an electronic copy
of the reviewed submittal 1202A (including all attachments) and a copy of the original contract bonds to the Division of Construction, Office
of Risk Management and Environmental Compliance at orm.insurance.review@dot.ca.gov.
Instructions to the DISTRICT PAYMENTS COORDINATOR
17. Upon receipt of submittal, enter existing Advantage CT document and vendor information.
18. Forward a copy of form STD. 204 to HQ Accounting (Payee.Data.Records@dot.ca.gov).
19. For address change, modify existing CT document vendor information in Advantage.
20. For business name change, create a new CT document in Advantage.
21. Enter new Advantage CT document and vendor information.
22. Print or type name, sign and date in the appropriate section.
23. Forward the completed submittal to the HQ Payments Coordinator.
Instructions to the HQ PAYMENTS COORDINATOR
24. Upon receipt of submittal, verify that CT document in Advantage has been updated prior to updating the Contract Administration System
(CAS).
25. Update Contractor Data in CAS.
26. Print or type name, sign and date in appropriate section.
27. Send a copy of the processed submittal (CEM-1202A and STD. 204) to the resident engineer, District Payments Coordinator and Division of
Accounting Office of Commodity and Contract Payables (OCCP)).
Instruction to the DISTRICT PAYMENTS COORDINATOR
28. Upon receipt of the processed submittal, verify requested change was made in Advantage.
Instruction to the RESIDENT ENGINEER
29. Provide a copy of the processed submittal to the CONTRACTOR.
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