1. General Information

Date         Firm's Name  

Mailing Address         Telephone         Fax  

Email         Type of work usually performed  

Contact Name for Inquiries         President or CEO  

Years in business under present name         Total office staff         Total field staff  

% Self-performed work         Avg Annual sales last 3 years         Work in place last year  

Bonding Company  

Insurance Agent       Phone #  

Please forward to your insurance agent the example of mandatory Certificate of Insurance. Each contractor must be able to provide this certificate if awarded a contract. Download Example Certificate of Insurance

Is firm in compliance with EEO?     yes     no       Is firm certified as MBE?     yes     no       Is firm certified as WBE?     yes     no

Work force is?     Union     Merit Shop

Bank Reference:

     Bank name  

     Bank Address  

     Phone         Contact Name  

Has firm
     failed to complete a contract?     yes     no
     been involved in bankruptcy reorganization?     yes     no
     had pending judgments, claims or suits against firm?     yes     no
(If yes to any of the preceding statements, submit details here.)

Has Owner or any Officer of the firm, in relation to a business within the past five years
     failed to complete a contract?     yes     no
     been involved in bankruptcy reorganization?     yes     no
     had pending judgments, claims or suits against firm?     yes     no
(If yes to any of the preceding statements, submit details here.)

List the four most significant projects completed in the last five years:

     • One

     Project Name         Project Location  

     Architect  

     Contract Amount         Date Completed  

     Reference Contact         Telephone  

     • Two

     Project Name         Project Location  

     Architect  

     Contract Amount         Date Completed  

     Reference Contact         Telephone  

     • Three

     Project Name         Project Location  

     Architect  

     Contract Amount         Date Completed  

     Reference Contact         Telephone  

     • Four

     Project Name         Project Location  

     Architect  

     Contract Amount         Date Completed  

     Reference Contact         Telephone  

List the three most significant projects currently under construction:

     • One

     Project Name         Project Location  

     Architect  

     Contract Amount         Anticipated Completion  

     Reference Contact         Telephone  

     • Two

     Project Name         Project Location  

     Architect  

     Contract Amount         Anticipated Completion  

     Reference Contact         Telephone  

     • Three

     Project Name         Project Location  

     Architect  

     Contract Amount         Anticipated Completion  

     Reference Contact         Telephone  

Is the firm qualified to do business in the state where Project is located?     yes     no

2. Financing

Submit an audited financial statement including your organization=s latest balance sheet and income statement showing the following items:

Current Assets     (e.g., cash, joint venture accounts, accounts receivable, notes received, accrued income, deposits, materials inventory and prepaid expenses)

Net Fixed Assets  

Other Assets  

Current Liabilities     (e.g., accounts payable, notes payable, accrued expenses, provision for income taxes, advances,accrued salaries and accrued payroll taxes)

        (e.g., capital stock, authorized and outstanding shares par values, earned surplus and retained earnings)

Name of firm preparing submitted financial statement         Date prepared  

Address of firm preparing submitted financial statement, and date thereof  

Is submitted financial statement for the identical organization named on page one?     yes     no
If not, when submitting financial statement, explain the relationship and financial responsibility of the organization whose financial statement is provided (e.g., parent-subsidiary).

Will the organization whose financial statement is attached act as guarantor of the contract for construction?     yes     no

What is your credit rating?  

3. Health & Safety

Does the company have a written safety program?     yes     no

With regard to your company's past year's OSHA 200 Log for injuries and illnesses:
     Number of Lost Workday Cases         Number of Restricted Workday Cases  
     Number of Cases with Medical Attention Only         Number of Fatalities  

List any general liability losses for the last three years
     
     
     

For the period covering 2000 to date, what is the:
     Total Number of Employees Hours Worked       Total Number Illness/Injury Hours  

With regard to Worker's Compensation insurance premiums, what is your Experience Modification Rate (EMR)?  

Are Tool Box Safety Meeting conducted     At the jobsite     At another location     Not conducted
     If yes, how frequently     Bi-weekly     Weekly     Other  

Are job site safety inspections conducted at each job site?     yes     no
     If yes, how frequently     Weekly     Monthly     Annually
     Name & Title of inspector:  

How is an accident and/or illness case recorded  

Will Construction Manager be given a copy of all accident reports on subject projects within 24 hours of occurrence?     yes     no

Does the company have a New Employee Orientation Safety Program?     yes     no

By submitting the form, applicant certifies that to the best of their knowledge the above information is true and correct, and agrees to furnish the required Certificate of Insurance as represented by example provided.
Name and Title of person submitting form on behalf of company  

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