General Information

Project Information

Project Name:

Projected Start Date:

Location:

Subcontractor/Vendor Information

Subcontractor/Vendor Name:

Address:

City:

State:

Postal Code:

Contact:

Phone:

Fax:

Email Address:

Is the Company owned or controlled by another Organization:

If Yes, please provide Owner Company Name:

Year the Company was founded:

Yearly Volume/Revenue

2019: $

2018: $

2017: $

Expected Total Gross Revenue for this year: $

Backlog: $

Proposed Value of Subcontract: $

Largest Contract Completed: $

Largest Contract Completed for this year: $

Has your Company Filed Bankruptcy in the last 5 years:

Licensing Information

Business License # (if Applicable):

Contractors License #:

Public Works License #:

Has Subcontractor's license been revoked or suspended?:

If Yes, please explain:

Tax ID #:

Open Shop or Union:

Credit Reference

Bank Name:

Bank Address:

City:

State:

Contact:

Phone:

Amount of Line of Credit: $

Balance Currently Available: $

Guarantors of Line of Credit:

Trade References

Trade Reference One

Name:

Address:

City:

State:

Zip Code:

Contact:

Phone:

Trade Reference Two

Name:

Address:

City:

State:

Zip Code:

Contact:

Phone:

Trade Reference Three

Name:

Address:

City:

State:

Zip Code:

Contact:

Phone:

List of all Vendors and Suppliers to be utilized on this project/contact info

1.

Vendor/Suppler Name:

Contact:

Telephone:

Value: $

Joint Check Required:

2.

Vendor/Suppler Name:

Contact:

Telephone:

Value: $

Joint Check Required:

3.

Vendor/Suppler Name:

Contact:

Telephone:

Value: $

Joint Check Required:

4.

Vendor/Suppler Name:

Contact:

Telephone:

Value: $

Joint Check Required:

5.

Vendor/Suppler Name:

Contact:

Telephone:

Value: $

Joint Check Required:

6.

Vendor/Suppler Name:

Contact:

Telephone:

Value: $

Joint Check Required:

7.

Vendor/Suppler Name:

Contact:

Telephone:

Value: $

Joint Check Required:

8.

Vendor/Suppler Name:

Contact:

Telephone:

Value: $

Joint Check Required:

9.

Vendor/Suppler Name:

Contact:

Telephone:

Value: $

Joint Check Required:

10.

Vendor/Suppler Name:

Contact:

Telephone:

Value: $

Joint Check Required:

Bonding Capacity

Name of bonding company:

Address:

City:

State:

Zip Code:

Contact:

Phone:

Bonding Capacity: $

Rate:

Cost to Secure Bond: $

Length of Bonding Relationship:

Date of last Bond:

Safety Information

Number of Permanent of Full Time Employees:

EMR (Experience Modification Rate:

Current:

2019:

2018:

2017:

TRIR (Total Recordable Incident Rate):

Current:

2019:

2018:

2017:

Does Subcontractor have Safety Programs for newly hired employees?

Does Subcontractor have Drug and Alcohol Testing Policy in place?

OSHA

Has subcontractor been issued any OSHA citations in the past three (3) years?

If yes, please explain:

Do you have a Competent Safety Person:

NAICS Code: (Can be found as https://www.naics.com/search

Judgments, Liens, Bankruptcies

Disclose and provide detailed information on any judgments, liens, bankruptcies, etc, in the last 5 years:

Upload Documents

Files must be less than 2mb

Upload Financials - Please submit a copy of your most current financials to include recent balance sheet and income statement. (Information submitted is confidential and will be reviewed by CFO/CEO/President only.) At a minimum please submit your most current financials from the last (1) year. i.e. Balance Sheet and Income/Profit Loss Statement.

**must be - pdf, docx, doc, txt, rtf, odt, pages

Upload Insurance Information - Please submit a copy of your insurance certificate(s) with endorsements per the attached Exhibit A (for Specific Projects) If prequal is being provided not for an specific project, Please see attached Sample Certificate Of Insurance with our Standard Insurance Requirements for your reference. (note: Insurance requirements are project specific to align with contractual requirements).

**must be - pdf, docx, doc, txt, rtf, odt, pages

Upload W-9

**must be - pdf, docx, doc, txt, rtf, odt, pages

Upload OSHA 300 Logs for the past three (3) years

**must be - pdf, docx, doc, txt, rtf, odt, pages

Signature

I herby certify that the information provided within this pre-qualification questionnaire is true and accurate to the best of my knowledge with no information withheld:

Name:

Title:

Name of Organization:

Date: