Agricultural/Vocational Building at East Hickman County High School
SECTION C-00300
STATE CONTRACTOR LICENSE INFORMATION FORM
Complete applicable portions of this form and attach to the outside of envelope containing the Bid
Bidder/Prime Contractor Name: Fellowship Construction, Inc.
Street Address: P.O. Box 310 (Mailing), 2668 Spencer Mill Rd.
City, State, Zip: Bon Aqua, TN 37025
If bid amount is $25,000 or greater, Bidder shall complete Tennessee Contractor License Information:
License No.: 49297
Expiration Date: 09/30/2027
License Classification: BC;
License Limit: Unlimited
Electrical Contractor
Plumbing Contractor
(should subcontract portion be $25,000 or greater, Tennessee
(should subcontract portion be $25,000 or greater, Tennessee
Contractor License Information shall also be provided)
Contractor License Information shall also be provided)
Name:
optimal Elctric Pro. LLC. Name:
License No.:
72880
License No.:
Schaffer 64174 Plumbing Inc.
License Classification:
CE
License Classification:
CML-A:
License Expiration Date: 11-30-2026
License Expiration Date: 11.30.2026
License Limit:
$1,417,366
License Limit:
$3,000,000
Heating, Ventilation and Air Conditioning (HVAC) Vertical Closed Loop Geothermal Heating and Cooling
Contractor
Contractor
(should subcontract portion be $25,000 or greater, Tennessee
(should subcontract portion be $25,000 or greater, Tennessee
Contractor License Information shall also be provided)
Contractor License Information shall also be provided)
Name:
Air Specialist of MiddleTN Name:
N/A
License No.:
43481
License No.:
N/A
License Classification:
cmc-c;
License Classification:
N/A
License Expiration Date: 4-30-2027
License Expiration Date:
N/A
License Limit:
$ 1,500,000
License Limit:
N/A
Roofing Contractor
Masonry Contractor
(should subcontract portion be $25,000 or greater, Tennessee
(should subcontract portion be $100,000 or greater, Tennessee
Contractor License Information shall also be provided)
Contractor License Information shall also be provided)
License No.:
Name: N/A 1A<25,000 Ger
Name:
N/A
License No.:
N/A
License Classification:
License Classification:
N/A
License Expiration Date
License Expiration Date:
N/A
License Limit:
License Limit:
N/A
Per Tennessee Department of Commerce & Insurance Board for Licensing Contractors Rule 0680-01-.24 (2): Award of the subcontract to
one not listed on the base bid envelope in violation of T.C.A. $32-6-119 will be subject to review and disciplinary action by the Board.
Contractor's Authorized Agent:
Contractor's Authorized Agent:
Julia Jimmy Irwin
(Signature)
(Printed Name)
Received by Finance Offk
REV 2014-01-10
10/16/2025 9.50AM Remay
AIA
Document A310ᵀ - 2010
Bid Bond
CONTRACTOR:
SURETY:
(Name, legal status and address)
(Name, legal status and principal place
Fellowship Construction, Inc.
of business)
Old Republic Surety Company
2668 Spencer Mill Road
This document has important legal
PO Box 1635
Bon Aqua, Tennessee 37025
consequences. Consultation with
Milwaukee, WI 53201-1635
an attomey is encouraged with
OWNER:
respect to its completion or
(Name, legal status and address)
modification.
Hickman County Board of Education
Any singular reference to
115 Murphree Ave
Contractor, Surety, Owner or
Centerville, TN 37033
other party shall be considered
BOND AMOUNT: Five Percent of the Total Amount Bid (5% of the Total Amount Bid)
plural where applicable.
PROJECT:
(Name, location or address, and Project number, if any)
East Hickman High School Ag Barn
7700 State HWY 7
Lyles, TN 37098
The Contractor and Surety bind themselves, their heirs, executors, administrators, successors and assigns, of jointly the and
and Surety are bound to the Owner in the amount set forth above, for the payment of which the
severally, the as time specified in the bid documents, or within such time period as may be agreed to by the of
Contractor provided herein The conditions of this Bond are such that if the Owner accepts the bid the Owner Contractor and
within and the Contractor either (1) enters into a contract with the Owner in accordance with terms admitted such
bid, in the gives of the Project and otherwise acceptable to the Owner, for the faithful performance the Owner the
Contractor, and such bond or bonds as may be specified in the bidding or Contract Documents, with a surety of such Contract
and not prompt to exceed the amount of this Bond, between the amount specified in said bid and larger then
for jurisdiction the payment of labor and material furnished in the prosecution thereof, or (2) pays such to amount
difference, the Owner in good faith contract with another party to perform the work covered by waives said bid, notice this of
for which shall be null may and void, otherwise to remain in full force and effect. The Surety hereby the bid. any Waiver
obligation between the Owner and Contractor to extend the time in which the Owner may accept the time for of
notice acceptance by of bids specified in the bid documents, and the Owner and Contractor shall obtain the Surety's for
an agreement the Surety shall not apply to any extension exceeding sixty (60) days in the aggregate beyond consent
an extension beyond sixty (60) days.
If this Bond is issued in connection with a subcontractor's bid to a Contractor, the term Contractor in this Bond shall
be deemed to be Subcontractor and the term Owner shall be deemed to be Contractor.
Bond has been furnished to comply with a statutory or other legal requirement in the location herefrom of the Project, and
When this in this Bond conflicting with said statutory or legal requirement shall be deemed deleted herein. When so
any provisions provision conforming to such statutory or other legal requirement shall be deemed incorporated law bond.
furnished, the intent is that this Bond shall be construed as a statutory bond and not as a common
16th
day of October, 2025.
Brooldui Signed and sealed this
Fellowship Construction, Inc
Old Republic Julie Surety Company
(Seal)
(Principal)
(Witness)
(Title) Jimm, Plasident
(Witness) Craig
Cray Whitlow, Partner
(Surety) Theyory L Attorney-in-Fact nunnen (Seal) I
(Title) Gregory L. Bennett Jr.)
CAUTION: You should sign an original AIA Contract Document. on which this text appears in RED. An original assures that
changes will not be obscured. 1970 and 2010 by The American institute of Architects. All rights reserved WARNING: AIA Document. This AIA or
Init.
AIA Document Document is protected A310ᵀ by 2010. U.S. Copyright Copyright © Law 1963, and International Treatles. Unauthorized prosecuted reproduction to the maximum or distribution extent possible of this under the tow:-
any Purchasers portion are of It, permitted may result to reproduce In severe ten civil (10) and copies criminal of this penalties, document and when will completed be To report copyright violations of AIA Contract Documents; asitio e-mail
The American Institute of Architects' legal counsel, copyright@aia.org.
OLD REPUBLIC SURETY COMPANY
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS: That OLD REPUBLIC SURETY COMPANY, a Wisconsin stock insurance corporation, does make, constitute and
appoint:
JAMES L. NOE III, CRAIG WHITLOW, GREGORY L. BENNETT JR., PAMELA PUSKARICH,
AMELIA CAIN, SETH CHAPMAN, ANDREW BENNETT, CHARLEY MYERS, JAMES MYERS of FRANKLIN, TN
its true and lawful Attorney(s)-in-Fact, with full power and authority for and on behalf of the company as surely, to execute and
deliver and affix the seal of the company thereto (if a seal is required). bonds, undertakings, recognizances or other written obligations in the nature thereof,
(other than bail bonds, bank depository bonds, mortgage deficiency bonds, mortgage guaranty bonds, guarantees of installment paper and note
guaranty bonds, self-insurance workers compensation bonds guaranteeing payment of benefits, or black lung bonds), as follows:
ALL WRITTEN INSTRUMENTS
and to bind OLD REPUBLIC SURETY COMPANY thereby, and all of the acts of said Attorneys-in-Fact, pursuant to these presents, are ratified and confirmed.
This appointment is made under and by authority of the board of directors at a special meeting held on February 18, 1982.
This Power of Attorney is signed and sealed by facsimile under and by the authority of the following resolutions adopted by the board of directors of the OLD
REPUBLIC SURETY COMPANY on February 18. 1982.
RESOLVED that, the president, any vice-president or assistant vice president, in conjunction with the secretary or any assistant secretary, may appoint
attorneys-in-fact or agents with authority as defined or limited in the instrument evidencing the appointment in each case, for and on behalf of the company to
execute and deliver and affix the seal of the company to bonds, undertakings, recognizances, and suretyship obligations of all kinds; and said officers may
remove any such attorney-in-fact or agent and revoke any Power of Attorney previously granted to such person.
RESOLVED FURTHER, that any bond, undertaking. recognizance, or suretyship obligation shall be valid and binding upon the Company
(i) when signed by the president, any vice president or assistant vice president, and attested and sealed (if a seal be required) by any secretary or assistant
secretary; or
(ii) when signed by the president, any vice president or assistant vice president, secretary or assistant secretary, and countersigned and sealed (if a seal be
required) by a duly authorized attorney-in-fact or agent; or
(iii) when duly executed and sealed (if a seal be required) by one or more attorneys-in-fact or agents pursuant to and within the limits of the authority
evidenced by the Power of Attorney issued by the company to such person or persons.
RESOLVED FURTHER that the signature of any authorized officer and the seal of the company may be affixed by facsimile to any Power of Attorney or
certification thereof authorizing the execution and delivery of any bond, undertaking. recognizance, or other suretyship obligations of the company; and such
signature and seal when so used shall have the same force and effect as though manually affixed.
IN WITNESS WHEREOF, OLD REPUBLIC SURETY COMPANY has caused these presents to be signed by its proper officer, and its corporate seal to be
affixed this
10th
day of
July
2025
SURETY
OLD REPUBLIC SURETY COMPANY
SEPUBLIC
CORPORATE
Assistant XTE Secretary
SEAL
OLD
COMPANY
Our Polic
1901
President
STATE OF WISCONSIN, COUNTY OF WAUKESHA - SS
On this
10th
day of
July
2025
personally came before me,
Alan Pavlic
and
Kevin J. Abitz
to me known to be the individuals and officers of the OLD REPUBLIC SURETY COMPANY
who executed the above instrument, and they each acknowledged the execution of the same, and being by me duly sworn, did severally depose and say: that
they are the said officers of the corporation aforesaid, and that the seal affixed to the above instrument is the seal of the corporation, and that said corporate seal
and their signatures as such officers were duly affixed and subscribed to the said instrument by the authority of the board of directors of said corporation.
PENNSIT
PUBLIC
Kathryn R. Peason
Notary Public
OF
My Commission Expires:
September 28, 2026
CERTIFICATE
(Expiration of notary's commission does not invalidate this instrument)
I, the undersigned, assistant secretary of the OLD REPUBLIS SURETY COMPANY, a Wisconsin corporation, CERTIFY that the foregoing and attached
Power of Attorney remains in full force and has not been revoked; and funhennore, that the Resolutions of the board of directors set forth in the Power of
Attorney, are now in force.
SURETY
CORPORATE
COMPANY
16th
October
2025
87-1074
SEAL
Signed and sealed at the City of Brooklield, WI this
day of
OLD
1001
XTE Assistant Secretary
ORSC 22262 (3-06)
INSURANCE GROUP OF AMERICA LLC
BID FORM
TO:
Hickman County Schools
Centerville, TN
PROJECT:
Agricultural/Vocational Building at East Hickman County High School
7700 TN-7
Lyles, TN 37098
The undersigned as Bidder acknowledges by his signature that he has visited and examined the
site of the proposed construction and has received and examined the documents titled Project
Manual for the Construction of "Agricultural/Vocational Building at East Hickman County High
School", the Drawings, and other documents dated July 18, 2025 and has included their
provisions in his Bid. The Bidder further acknowledges that he has received the following
Addenda:
Addendum No.
1
Dated 10/09/2025
Dated
Addendum No.
Dated
Addendum No.
In submitting this Bid, the Bidder agrees:
1.
To hold open his Bid for 30 days from the date shown above.
2.
To enter into and execute a Contract, if awarded, on the basis of this Bid,
and to furnish the required Bonds and Insurance.
3.
To accomplish Work in accord with the Contract Documents.
4.
To complete the Work within 180 calendar days from and including the
date of the Notice to Proceed.
5.
Liquidated Damages will be assessed in the amount of five hundred
dollars ($500.00) per calendar day for failure to complete on time.
The Bidder agrees to construct the Work of the base bid for this project for the lump sum price of
BASE BID
(show amount in both words and figures):
Five hundred eighty thousand
dollars $580,000.00
ALTERNATES - Not Applicable
UNIT PRICES - Not Applicable
The Bidder acknowledges by his signature that he agrees to requirements contained in the
Invitation to Bid and the Instructions to Bidders and, that should he fail to execute a Contract with
the Owner, should the Owner award said Contact to him, that the Owner may rightfully collect the
sum of the Bid Bond.
Fellowship Construction, Inc.
Company
Date 10/16/2025
Authorized Signature
NOTE: If Bidder is a corporation, Bid must be signed by an Officer of the Corporation licensed to
bind the Corporation to this Agreement.
1
ATTESTATION REGARDING PERSONNEL USED IN
CONTRACT/AGREEMENT PERFORMANCE
SUBJECT AGREEMENT NUMBER:
Architect Project # 1402.1
ENGINEER'S LEGAL ENTITY NAME:
Fellowship Construction, Inc.
FEDERAL EMPLOYER IDENTIFICATION NUMBER:
(or Social Security Number)
45-1139837
The Contractor/Engineer, identified above, does hereby attest, certify, warrant, and
assure that the Contractor/Engineer shall not knowingly utilize the services of an illegal
immigrant in the performance of this Agreement and shall not knowingly utilize the
services of any subcontractor who will utilize the services of an illegal immigrant in the
performance of this Agreement.
SIGNATURE & DATE:
bind the individual is not the chief executive or president, this
NOTICE: Juille signed by an individual empowered to contractually
10/16/2025
document the individual's authority to contractually bind the
Contractor/Engineer.
Revised: June 2025
SECTION 00200
9. REQUEST FOR TAXPAYER IDENTIFICATION
NUMBER AND CERTIFICATION
W-9
Request for Taxpayer
Give Form to the
Form
(Rev. October 2018)
Identification Number and Certification
requester. Do not
Department of the Treasury
send to the IRS.
Internal Revenue Service
Go to www.irs.gov/FormW9 for instructions and the latest information.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
Fellowship Construction, Inc.
2 Business name/disregarded entity name, if different from above
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the
4 Exemptions (codes apply only to
following seven boxes.
certain entities, not individuals: see
instructions on page 3):
See Specific Instructions on page 3.
Individual/sole proprietor or
C Corporation
S Corporation
Partnership
Trust/estate
single-member LLC
Exempt payee code (if any)
Print or type.
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)
Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check
Exemption from FATCA reporting
LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is
code (if any)
another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, 8 single-member LLC that
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
Other (see instructions)
(Applies to accounts maintained outside the US.)
5 Address (number, street, and apt. or suite no.) See instructions.
Requester's name and address (optional)
P.O. Box 310, 2668 Spencer Mill Rd
6 City, state, and ZIP code
Bon Aqua, TN 37025
7 List account number(s) here (optional)
Part I
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
Social security number
backup withholding. For individuals, this is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other
-
-
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later.
or
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and
Employer identification number
Number To Give the Requester for guidelines on whose number to enter.
45 - 1139837
Part
II
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) 1 have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above If you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part Ii, later.
Section references are to Jack the Internal Revenue Code unless otherwise
Sign
Signature of
Here
U.S. person
Jimmy Irwin, President
Date
10/16/2025
General Instructions
Form 1099-DIV (dividends, including those from stocks or mutual
funds)
Form 1099-MISC (various types of income, prizes, awards, or gross
noted.
proceeds)
Future developments. For the latest information about developments
Form 1099-B (stock or mutual fund sales and certain other
related to Form W-9 and its instructions, such as legislation enacted
transactions by brokers)
after they were published, go to www.irs.gov/FormW9.
Form 1099-S (proceeds from real estate transactions)
Purpose of Form
Form 1099-K (merchant card and third party network transactions)
An individual or entity (Form W-9 requester) who is required to file an
Form 1098 (home mortgage interest), 1098-E (student loan interest),
information return with the IRS must obtain your correct taxpayer
1098-T (tuition)
identification number (TIN) which may be your social security number
Form 1099-C (canceled debt)
(SSN). individual taxpayer identification number (ITIN). adoption
taxpayer identification number (ATIN), or employer identification number
Form 1099-A (acquisition or abandonment of secured property)
(EIN). to report on an information return the amount paid to you, or other
Use Form W-9 only if you are a U.S. person (including a resident
amount reportable on an information return. Examples of information
alien), to provide your correct TIN.
returns include, but are not limited to, the following.
If you do not return Form W-9 to the requester with a TIN, you might
Form 1099-INT (interest earned or paid)
be subject to backup withholding. See What is backup withholding,
later.
Cat. No. 10231X
Form W-9 (Rev. 10-2018)
SECTION 00200
FORM OF PROPOSAL
8. CONTRACTOR/SUBCONTRACTOR CONTACT INFORMATION
Company Please provide the requested information for each representative of your company responsible for the positions or areas listed below:
Name: Fellowship Construction Inc.
This information must be submitted with the bid.
SITE SUPERINTENDENT
CONTRACT ADMINISTRATOR
NAME:
Jamie Irwin
NAME:
Steve Davis, Mark Allen or Chris Brown
UNE1
UNIT
ADDRESS
ADDRESS
P.O. Box 310
:
P.O. Box 310
:
LINE 2
LINE 2
Bon Aqua, TN 37025
Bon Aqua, TN 37025
PHONE:
(615) 412-4446
PHONE:
(615) 412-4446
jrwin@fellowshipconstruction.com
EMAIL:
EMAIL:
PROJECT MANAGER
CERTIFICATES OF INSURANCE
Brooke Irwin
NAME:
Jamie Irwin
NAME:
LINET
UNE 1
ADDRESS
ADDRESS
P.O. Box 310
:
P.O. Box 310
:
LINE 2
LINE :
Bon Aqua. TN 37025
Bon Aqua. TN 37025
PHONE:
(615) 412-4446
PHONE:
(615) 412-4446
EMAIL:
birwin@fellowshipconstruction.com
EMAIL:
jrwin@fellowshipconstruction.com
ESTIMATOR /CHANGE ORDER
PRICING
CERTIFIED PAYROLLS
Brooke Irwin
NAME:
Jamie Irwin
NAME:
LINET
LINE T
ADDRESS
ADDRESS
P.O. Box 310
P.O. Box 310
:
:
LINE 2
LINE 2
Bon Aqua, TN 37025
Bon Aqua, TN 37025
(615) 412-4446
PHONE:
(615) 412-4446
PHONE:
EMAIL:
jirwin@fellowshipconstruction.com
EMAIL:
birwin@fellowshipconstruction.com
CHANGE ORDER ADMINISTRATOR
PAY APPLICATIONS
(IF NOT PROJECT MANAGER)
NAME:
Jamie Irwin
UNET
ADDRESS
P.O. Box 310
NAME:
Jamie Irwin
:
UNIT
UNE?
ADDRESS
Bon Aqua, TN 37025
:
P.O. Box 310
LINE 2
(615) 412-4446
Bon Aqua, TN 37025
PHONE:
EMAIL:
jirwin@fellowshipconstruction.com
PHONE:
(615) 412-4446
EMAIL:
jirwin@fellowshipconstruction.com
SECTION 00200
FORM OF PROPOSAL
SECTION 00200
FORM OF PROPOSAL
7. IDENTIFICATION OF SMALL, MINORITY, WOMEN, AND VETERAN OWNED BUSINESS
BIDDER/CONTRACTOR, SUBCONTRACTOR, AND MATERIAL SUPPLIER
Utilization of Small, Minority, Women, and Veteran owned contracting and material supplier businesses is
encouraged and supported whenever possible on public school projects.
This form should be submitted, along with other documents required within (4 days) of Bid Opening.
Bidder
Fellowship Construction, Inc.
is a (circle applicable SBE, MBE, WBE, VOSB, not applicable)
The following Small, Minority, Women, or Veteran Owned business will be providing subcontracting or
supplying materials as part of the bid by
Fellowship Construction, Inc.
.
Insert Name of Entity submitting Bid
Business Name
City, State
SBE, MBE, WBE, VOSB, (other)
N/A
The following Small, Minority, Women, or Veteran Owned businesses were contacted to obtain proposals
when the bid submitted by
Fellowship Construction. Inc.
was being prepared.
Insert Name of Entity submitting Bid
Business Name
City, State
SBE, MBE, WBE, VOSB, (other)
Nickell Company, LLC.
Columbia, TN
SBE, WBE
Crawford Door Sales of Nashville
Nashville, TN
SBE
Commercial Installation, LLC.
Clarksville, TN
MBE
Wall Brothers Glass, LLC.
Clarksville, TN
SBE
Isenhour Door Products
Nashville, TN
SBE
Slayden Door & Hardware
La Vergne, TN
SBE
Planet Glass
Columbia, TN
MBE
C & R Services, Inc.
Nashville, TN
SBE, WBE
Parthenon Plumbing
Nashville, TN
SBE
American Comm. Indus. Electric
Nashville TN
SBE
Maryland Electric Company, LLC.
Kingston Springs, TN
WBE
Crown Paving
Greenbrier, TN
WBE
Sessions Paving Company
Nashville, TN
SBE
SECTION 00200
FORM OF PROPOSAL
THE
STATE
AGRICULTURE
)
7796
STATE OF TENNESSEE
NON-BOYCOTT OF ISRAEL CERTIFICATION
The Bidder certifies that it is not currently engaged in, and will not for the duration of the contract
engage in, a boycott of Israel as defined by Tenn. Code Ann. § 12-4-119. This provision shall not apply to
contracts with a total value of less than two hundred fifty thousand dollars ($250,000) or to contractors
with less than ten (10) employees.
According to the law, a boycott of Israel means engaging in refusals to deal, terminating business
activities, or other commercial actions that are intended to limit commercial relations with Israel, or
companies doing business in or with Israel or authorized by, licensed by, or organized under the laws of
the State of Israel to do business, or persons or entities doing business in Israel, when such actions are
taken:
1) In compliance with, or adherence to, calls for a boycott of Israel, or
2) In a manner that discriminates on the basis of nationality, national origin, religion, or other
unreasonable basis, and is not based on a valid business reason. Tenn. Code Ann. § 12-4-119.
Juicle Jimmy Irwin, President
10/16/2025
Signature of Authorized Representative
Date
(615) 412-4446
jirwin@fellowshipconstruction.com
Printed Name
Phone Number / Email Address
OF
THE
SEAL
STATE OF
STATES
OF
AGRICULTURE COMMERC 7796 J
STATE OF TENNESSEE
IRAN DIVESTMENT ACT CERTIFICATION
SUBJECT CONTRACT NUMBER(S):
Architect's Project No. 1402.1
CONTRACTOR LEGAL ENTITY NAME:
Fellowship Construction, Inc.
EDISON SUPPLIER IDENTIFICATION NUMBER:
The Iran Divestment Act, Tenn. Code Ann. $ 12-12-101 et. seq. requires a person that attempts to contract with the
state, including a contract renewal or assumption, to certify at the time the bid is submitted or the contract is entered
into, renewed, or assigned, that the person or the assignee is not identified on a list created pursuant to § 12-12-106.
Currently, the list is available online at the following website: https://www.tn.gov/generalservices/procurement/central-
procurement-office--cpo-/library-/public-information-library.html
The Contractor, identified above, certifies by signature below that it is not included on the list of persons created
pursuant to Tenn. Code Ann. § Sicla 12-12/106 of the Iran Divestment Act.
CONTRACTOR SIGNATURE
NOTICE: This certification MUST be signed by an individual with legal capacity to contractually bind the Contractor.
Jimmy Irwin, President
PRINTED NAME AND TITLE OF SIGNATORY
10/16/2025
DATE
SECTION 00200
FORM OF PROPOSAL
6. CONFLICT OF INTEREST
CONFLICT OF INTEREST
Hickman County Government
Conflict of Interest Disclosure Form
The County Financial Management System of 1981 contains the most stringent conflict of interest provisions.
TCA 5-21-121 provides:
(a) The director, purchasing agent, members of the committee, members of the county legislative body
or other officials, employees, or members of the board of education or highway commission shall
not be financially interested or have any personal beneficial interest, either directly or indirectly, in
the purchase of any supplies, materials, equipment or contractual services for the county.
(b) No firm, corporation, partnership, association, or individual furnishing any such supplies, materials,
equipment or contractual services shall give or offer, nor shall the director or purchasing agent or
any assistant or employee accept or receive directly or indirectly from any person, firm, corporation,
partnership, or association to whom any contract may be awarded by rebate, gift or otherwise, any
money or other things of value whatsoever, or any promise, obligation or contract for future reward
or compensation.
Date: 10/16/2025
Name: Fellowship Construction, Inc. - Jimmy Irwin President
Please describe below any relationships, transactions, positions you hold (volunteer or otherwise) or circumstances that
you believe could contribute to a conflict of interest:
I
have no conflict of interest to report.
I have the following conflict of interest to report (please specify any boards or committees you (and/or your
spouse) sit on, the name of your employer and any business you or your spouse may own.
Date: 10/16/2025
I hereby certify that the information set forth above Jick is true and to the best of my knowledge.
Signature:
SECTION 00200
FORM OF PROPOSAL

## Table 1

| Name: | optimal Elctric Pro. |
| --- | --- |
| License No.: | 72880 |
| License Classification: | CE |
| License Expiration Date: | 11-30-2026 |
| License Limit: | $1,417,366 |

## Table 2

| Name: | Schaffer Plumbing Inc. |
| --- | --- |
| License No.: | 64174 |
| License Classification: | CML-A: |
| License Expiration Date: | 11.30.2026 |
| License Limit: | $3,000,000 |

## Table 3

| Name: | N/A |
| --- | --- |
| License No.: | N/A |
| License Classification: | N/A |
| License Expiration Date: | N/A |
| License Limit: | N/A |

## Table 4

| Name: | Air Specialist of MiddleTN |
| --- | --- |
| License No.: | 43481 |
| License Classification: | cmc-c; |
| License Expiration Date: | 4-30-2027 |
| License Limit: | $ 1,500,000 |

## Table 5

| Name: | N/A |
| --- | --- |
| License No.: | N/A |
| License Classification: | N/A |
| License Expiration Date: | N/A |
| License Limit: | N/A |

## Table 6

|  | Fellowship Construction, Inc |
| --- | --- |
| Brooldui | Julie (Seal) (Principal) |
| (Witness) | Old Republic Surety Company (Title) Jimm, Plasident |
| Cray | (Surety) Theyory L nunnen (Seal) |
| (Witness) Craig Whitlow, Partner | Attorney-in-Fact (Title) Gregory L. Bennett Jr.) |
| CAUTION: You should sign an original AIA Contract Document. changes will not be obscured. | on which this text appears in RED. An original assures that reserved WARNING: This AIA |
| 1970 and 2010 by The AIA Document Document is protected A310ᵀ by 2010. U.S. Copyright Copyright © Law 1963, and International Treatles. and | American institute of Architects. All rights AIA Document. or Unauthorized prosecuted reproduction to the maximum or distribution extent possible of this under the tow:- will be e-mail |

## Table 7

|  | SURETY CORPORATE SEAL COMPANY Signed and sealed at the City of Brooklield, WI this | 16th | October day of | 2025 |
| --- | --- | --- | --- | --- |
| 87-1074 ORSC 22262 (3-06) | OLD 1001 |  | XTE Assistant Secretary |  |

## Table 8

| TO: | Hickman County Schools Centerville, TN |
| --- | --- |
| PROJECT: | Agricultural/Vocational Building at East Hickman County High School 7700 TN-7 Lyles, TN 37098 |

## Table 9

| SUBJECT AGREEMENT NUMBER: | Architect Project # 1402.1 |
| --- | --- |
| ENGINEER'S LEGAL ENTITY NAME: | Fellowship Construction, Inc. |
| FEDERAL EMPLOYER IDENTIFICATION NUMBER: (or Social Security Number) | 45-1139837 |

## Table 10

| 5 Address (number, street, and apt. or suite no.) See instructions. | Requester's name and address (optional) |
| --- | --- |
| P.O. Box 310, 2668 Spencer Mill Rd |  |
| 6 City, state, and ZIP code |  |
| Bon Aqua, TN 37025 |  |
| 7 List account number(s) here (optional) |  |
|  |  |

## Table 11

| Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. | Social security number - - or |
| --- | --- |
| Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter. | Employer identification number 45 - 1139837 |

## Table 12

| Under | penalties of perjury, | I certify that: |
| --- | --- | --- |
| 1. The | number shown on | this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and |
| 2. I am not Service no longer | subject to (IRS) that I am subject to | backup withholding because: (a) I am exempt from backup withholding, or (b) 1 have not been notified by the Internal Revenue subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am backup withholding; and |
| 3. I am a | U.S. citizen or | other U.S. person (defined below); and |
| 4. The | FATCA code(s) | entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. |
| Certification you have acquisition other than | instructions. failed to report all or abandonment interest and | You must cross out item 2 above If you have been notified by the IRS that you are currently subject to backup withholding because interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part Ii, later. |
| Sign Here | Signature of U.S. person | Jimmy Irwin, President Date 10/16/2025 |

## Table 13

| NAME: | Steve Davis, Mark Allen or Chris Brown |
| --- | --- |
| ADDRESS : | UNE1 P.O. Box 310 |
|  | LINE 2 Bon Aqua, TN 37025 |
| PHONE: | (615) 412-4446 |
| EMAIL: |  |

## Table 14

| NAME: | Jamie Irwin |
| --- | --- |
| ADDRESS : | UNIT P.O. Box 310 |
|  | LINE 2 Bon Aqua, TN 37025 |
| PHONE: | (615) 412-4446 |
| EMAIL: | jrwin@fellowshipconstruction.com |

## Table 15

| NAME: | Jamie Irwin |
| --- | --- |
| ADDRESS : | LINET P.O. Box 310 |
|  | LINE 2 Bon Aqua. TN 37025 |
| PHONE: | (615) 412-4446 |
| EMAIL: | jrwin@fellowshipconstruction.com |

## Table 16

| NAME: | Brooke Irwin |
| --- | --- |
| ADDRESS : | UNE 1 P.O. Box 310 |
|  | LINE : Bon Aqua. TN 37025 |
| PHONE: | (615) 412-4446 |
| EMAIL: | birwin@fellowshipconstruction.com |

## Table 17

| NAME: | Jamie Irwin |
| --- | --- |
| ADDRESS : | LINET P.O. Box 310 |
|  | LINE 2 Bon Aqua, TN 37025 |
| PHONE: | (615) 412-4446 |
| EMAIL: | jirwin@fellowshipconstruction.com |

## Table 18

|  |  |
| --- | --- |
| NAME: | Brooke Irwin |
| ADDRESS : | LINE T P.O. Box 310 LINE 2 Bon Aqua, TN 37025 |
| PHONE: | (615) 412-4446 |
| EMAIL: | birwin@fellowshipconstruction.com |

## Table 19

| NAME: | Jamie Irwin |
| --- | --- |
| ADDRESS : | UNET P.O. Box 310 |
|  | UNE? Bon Aqua, TN 37025 |
| PHONE: | (615) 412-4446 |
| EMAIL: | jirwin@fellowshipconstruction.com |

## Table 20

| NAME: | Jamie Irwin |
| --- | --- |
| ADDRESS | UNIT |
| : | P.O. Box 310 |
|  | LINE 2 Bon Aqua, TN 37025 |
| PHONE: | (615) 412-4446 |
| EMAIL: | jirwin@fellowshipconstruction.com |

## Table 21

| Business Name | City, State | SBE, MBE, WBE, VOSB, (other) |
| --- | --- | --- |
| N/A |  |  |
|  |  |  |
|  |  |  |
|  |  |  |
|  |  |  |
|  |  |  |
|  |  |  |
|  |  |  |

## Table 22

| Nickell Company, LLC. | Columbia, TN | SBE, WBE |
| --- | --- | --- |
| Crawford Door Sales of Nashville | Nashville, TN | SBE |
| Commercial Installation, LLC. | Clarksville, TN | MBE |
| Wall Brothers Glass, LLC. | Clarksville, TN | SBE |
| Isenhour Door Products | Nashville, TN | SBE |
| Slayden Door & Hardware | La Vergne, TN | SBE |
| Planet Glass | Columbia, TN | MBE |
| C & R Services, Inc. | Nashville, TN | SBE, WBE |

## Table 23

| Parthenon Plumbing | Nashville, TN | SBE |
| --- | --- | --- |
| American Comm. Indus. Electric | Nashville TN | SBE |
| Maryland Electric Company, LLC. | Kingston Springs, TN | WBE |
| Crown Paving | Greenbrier, TN | WBE |
| Sessions Paving Company | Nashville, TN | SBE |

## Table 24

|  | 10/16/2025 |
| --- | --- |
| Juicle Signature of Authorized Representative | Date |
| Jimmy Irwin, President | (615) 412-4446 jirwin@fellowshipconstruction.com |
| Printed Name | Phone Number / Email Address |

## Table 25

| SUBJECT CONTRACT NUMBER(S): | Architect's Project No. 1402.1 |
| --- | --- |
| CONTRACTOR LEGAL ENTITY NAME: | Fellowship Construction, Inc. |
| EDISON SUPPLIER IDENTIFICATION NUMBER: |  |