SUB-CONTRACTOR ONLINE PRE-QUALIFICATION FORM Page 1 of 5 1 2 3 4 5 Company Name Contact Name Email Phone Number Major Trade(s) A) B) C) D) Company Information Company Name Address City State Zip Code Telephone Fax Contact Person Years in Business Years in Business Under Present Name Total Number of Employees Office: Field: Shop: List Geographic Areas Covered: Geographic Areas List Trades and State(s) in Which Company Holds Licenses: State 1 License Number 1 State 2 License Number 2 State 3 License Number 3 State 4 License Number 4 Bank References Bank Reference1: Contact 1: Phone 1: Bank Reference 2: Contact 2: Phone 2: List Five Trade References (Contact & Phone): Contact 1: Phone 1: Contact 2: Phone 2: Contact 3: Phone 3: Contact 4: Phone 4: Contact 5: Phone 5: List Five General Contractor References (Contact & Phone): Contact 1: Phone 1: Contact 2: Phone 2: Contact 3: Phone 3: Contact 4: Phone 4: Contact 5: Phone 5: List Three Major Projects Presently Under Construction: Project 1: Project Name: Owner: Contact: Phone: Start Date: Finish Date: Contract Amount: Project 2: Project Name: Owner: Contact: Phone: Start Date: Finish Date: Contract Amount: Project 3: Project Name: Owner: Contact: Phone: Start Date: Finish Date: Contract Amount: List Revenue for the Past Three Years: 2015: Private Work: Public Work: 2014: Private Work: Public Work: 2013: Private Work: Public Work: Current Backlog of Uncompleted Work: Dollar Amount: Have You Ever Failed to Complete a Project? Yes No If yes, explain: Do You Have a Written Safety Program? Yes No Do You Require Your Field Employees to be OSHA 10 Hour Certified? Yes No Have You Been Cited by OSHA Within the Last Four Years? Yes No If yes, explain: General Liability Limit: Insurance Company: Broker: Phone: Umbrella Limit: Insurance Company: Broker: Phone" Workers Compensation Limit: Insurance Company: Broker: Phone: Bondable Are You Bondable? Yes No Surety Co. ($): Single Job Limit ($): Aggregate ($): Broker: Phone: Workers Compensation Modification Rating (EMR for Last Three Years) 2015: 2014: 2013: Do you offer Health Insurance for your Employees? If yes: Do You Have a Formal Employee Training Program? What Means Do You Use for Employee Training (indicate all that apply)? In House Training Programs Yes No Gould Institute (ABC) Yes No Trade School/Apprenticeship Program Yes No Continuing Education Programs Yes No Seminars and Workshops Yes No Do You Qualify as an Approved Disadvantaged Business Enterprise (DBE)? Yes No (Please Attach a Copy of the Certification) Do You Qualify as an Approved Minority Business Enterprise (MBE)? Yes No (Please Attach a Copy of the Certification) Does Your Company Have Any Particular Specialized Areas of Expertise? Is Your Firm a Member of Any Trade/Business Associations? Minimum Size of Job Your Firm Would Like to Perform ($): Maximum Size of Job Your Firm Would Like to Perform ($): Has your organization ever petitioned for bankruptcy, failed in business, defaulted or been terminated on a contract awarded to you? If so, please explain in detail: Has your organization ever had a claim made against it for improper, delayed, defective or non-compliant or failure to meet warranty obligations? If so, please explain in detail: Signature Submitted By: Title: Prev Next