Pre-Qualification Form

APPLICANT INFORMATION:

Company Name*

Complete Address*

Phone Number*

Fax Number*

Contact Name*

Email Address*

Federal Tax ID #*

Type of Company*
CorporationPartnershipSole Proprietorship

Date Formed*

Number of Employees*

Salaried*

Hourly*

Average work in place during last 5 years*

Work Under Contract*

Average project size in place last year*

Uncompleted Backlog*

Size of Projects Preferred*

Project Location Preferred*

Does the company have offices, plants or warehouses at other locations?* YesNo

If yes, list addresses:

BONDING CAPACITY:

Are you able to bond projects?* YesNo

Bonding Rate*

Single Project Limit*

Aggregate Limit*

Bonding Company/Address*

Agent Name/Phone#*

INSURANCE INFORMATION:

Worker’s Compensation Experience Modifier:

Current Experience Modifier*

Effective Date (Month and Year)*

You are required to verify your current workers’ compensation experience modifier. If your experience modifier is .90 or higher, you may be asked to provide a copy of additional information for up to the past four years.

General Liability Limits:

Per Occurrences*

Aggregate*

Insurance Company/Address*

Agent Name/Phone#*

Agent Name/Phone#*

BANK REFERENCE:

Does the company have a line of credit from any lending institution? YesNo

Please list the Lender's name and address, as well as, the Lending Officer's name and phone number.

Lender 1:

Lender's Name:

Lender's Address:

Lending Officer's Name:

Lending Officer's Phone Number:

Lender 2:

Lender's Name:

Lender's Address:

Lending Officer's Name:

Lending Officer's Phone Number:

Lender 3:

Lender's Name:

Lender's Address:

Lending Officer's Name:

Lending Officer's Phone Number:

COMPLETED PROJECTS:

List four (4) representative projects completed in the last five (5) years.

Project 1:

Name of Project:

General Contractor:

Contact Name:

Contact Phone Number:

Contract Amount:

Completion Date:

Project 2:

Name of Project:

General Contractor:

Contact Name:

Contact Phone Number:

Contract Amount:

Completion Date:

Project 3:

Name of Project:

General Contractor:

Contact Name:

Contact Phone Number:

Contract Amount:

Completion Date:

Project 4:

Name of Project:

General Contractor:

Contact Name:

Contact Phone Number:

Contract Amount:

Completion Date:

CURRENT PROJECTS:

List four (4) representative projects currently under construction.

Project 1:

Name of Project:

General Contractor:

Contact Name:

Contact Phone Number:

Contract Amount:

Completion Date:

Project 2:

Name of Project:

General Contractor:

Contact Name:

Contact Phone Number:

Contract Amount:

Completion Date:

Project 3:

Name of Project:

General Contractor:

Contact Name:

Contact Phone Number:

Contract Amount:

Completion Date:

Project 4:

Name of Project:

General Contractor:

Contact Name:

Contact Phone Number:

Contract Amount:

Completion Date:

TRADE REFERENCES:

List three (3) of your subcontractors of suppliers.

Subcontractor/Supplier 1:

Company Name:

Address:

Phone Number:

Contact Name:

Subcontractor/Supplier 2:

Company Name:

Address:

Phone Number:

Contact Name:

Subcontractor/Supplier 3:

Company Name:

Address:

Phone Number:

Contact Name:

CLIENT REFERENCES:

List three (3) clients.

Subcontractor/Supplier 1:

Company Name:

Address:

Phone Number:

Contact Name:

Subcontractor/Supplier 2:

Company Name:

Address:

Phone Number:

Contact Name:

Subcontractor/Supplier 3:

Company Name:

Address:

Phone Number:

Contact Name:

COMPANY'S COMMITMENT TO MITIGATING THE ENVIRONMENTAL IMPACTS OF CONSTRUCTION

Does the company...

  • Have an environmental mission statement and/or policy? If so, please provide a copy. YesNo
  • Have a waste reduction and recycling program? If so, please provide a copy. YesNo
  • Educate employees and vendors about this program? YesNo
  • Participate in the salvage and/or reuse of waste materials? YesNo
    If so, please provide information on types, quantities and destination(s)
  • Utilize recycled content construction material? YesNo
    If so, please provide information on types and quantities.

Enviromental Mission Attachment:
Reduction and Recycling Program Attachment:

OTHER INFORMATION

In the past five years, has the company...

  • Operated under any other name? YesNo
  • Had any liens filed against it by any of its subcontractors or suppliers? YesNo
  • Ever failed co complete a contract, been defaulted, or had a contract terminated? YesNo
  • Had liquidated damages assessed against it upon completion of a project? YesNo
  • Or any of its key people been a party to a bankruptcy or reorganization proceeding? YesNo
  • Or any of its key people been involved in any lawsuit arising from a project? YesNo
  • Or any of its key people been investigated for or found to have committed a violation of any labor laws? YesNo
  • Or any of its key people been investigated for or found to have committed a serious OSHA violation (you can research this at http://www.osha.gov/oshstats/) ? YesNo
  • Or any of its key people been investigated for or found to have committed a violation of state, federal, or local laws? YesNo

Give details for any yes answer.

Contractor's License No.

Please Attach:

Insurance Certificate:

Copy of all Contractor’s License:

Audited or Reviewed Financial Statements:
Internal Financial Statements:
Any additional information: