Subcontractor Qualification Statement Form

Project Name that you have an interest: *

Your Company name: *

Company Address: *

City: *  State: *  Zip: *

Contact Name: *  

Title:*  e-mail *

Phone:  * Fax: *  Mobile: *

What areas will you work in?: *  

Bus. Type  Corporation S-Corp Partnership Sole Prop LLC *  

Number of full time Employees: * Yrs in Bus. 1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years 21 - 25 Years 26 to 30 Years 31 or More Years * 

FEIN Number *  

What are your company affiliations: Merit Shop Open Shop Union Shop *     

List the Scopes of work that your company performs:    *

List the geographic areas where your company performs work:*

Please fill out the number of employees that you have in each category

Management:  *  Administration:  *  Supervisors:    *   

Tradesman:      *      Others:         *     

Can you provide an identifiable supervisor on this project if required  Yes No  * 

Client References: (Please list 2 largest projects that the company has completed in the last 2 years.                                                       

A)    Project: *

         Contract Amount:  $*

         Company Name: *

         Contact Person:  *

         Phone Number:  *

B)    Project: *

         Contract Amount:  $*

         Company Name: *

         Contact Person:  *

          Phone Number: *

SUPPLIER REFERENCES:

A)    Company Name:  *

         Contact Name:    *

         Phone Number:    *

B)    Company Name:   *  

       Contact Name:      *

       Phone Number:   *

INSURANCE INFO : (please check the following insurance that  you have in place)

A)    Workers Compensation:         *

B)    General Liability:                    *

C)    Automobile:                           *

CAN YOUR COMPANY SECURE A PERFORMANCE BOND?  YES NO *

DO YOU HAVE A SAFETY PROGRAM ? YES NO *

Your Name: *

Your Title:   *

Today's Date: *