SUB-CONTRACTOR REGISTRATION – Hybrid One Construction

1) SUB-CONTRACTOR IDENTITY

Company Name*

Area of Expertise*

Email*

Phone*

Address*

Tax ID / SS Number*

Contact Person*

Type of Company*

Date company formed

Total number of employees*

States in which company is legally qualified to do business (Include type and license numbers)

Names & Titles of Key Personnel in Company

Has the company operated under any other name in the past five years?

YesNo

If yes, give name(s)?

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

YesNo

If yes, give location(s)?

2) MBE/WBE/SBE CERTIFICATION

Is the company a Minority Business Enterprise (MBE), Women Business Enterprise (WBE), Small Business Enterprise (SBE) or any other type of certified business enterprise?

YesNo

If yes, what type?

3) FINANCIAL INFORMATION

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

If yes, please provide details:

Lender's name, Address, Officer's name, Phone:*

Do you have the ability to bond projects?*

YesNo

If yes, date of last bonded project:

Single project limit

Aggregate Limit

Bonding Company Name, Address:

4) SAFETY RECORD

In the past 5 years, has your company or any of its key personnel been investigated for or found to have committed a serious OSHA violation?
*

YesNo

If yes, provide details:

What is your current Workman's Compensation EMR rate?
Please attach a copy of current EMR at end of form

Do you have written employee safety policy & program?*

YesNo

Are there any open or aggregate liability claims that would impair your ability to insure a project?*

Yes (attach explanation)No

5) OTHER INFORMATION

Has your company or any of its personnel been a party to a bankruptcy or reorganization proceeding?*

YesNo

If yes, give date:

During the past 5 years, have any liens been filed against you by any of your sub-contractors or suppliers?*

YesNo

If yes, give details:

Have you ever failed to complete a contract, been defaulted, or had a contract terminated?*

YesNo

If yes, give dates and details:*

In the past 5 years, has your company or any of its key personnel been involved in any lawsuits arising from construction projects?*

YesNo

If yes, give details:

5) REFERENCES

Current projects Include name of project, scope of work, contract amount and completion date*

Trade References Include name of project, scope of work, contract amount and completion date*

Client References List 3 clients, include names and phone numbers*

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SUBCONTRACTOR PRE-QUALIFICATION FORM

1) SUB-CONTRACTOR IDENTITY

2) MBE/WBE/SBE CERTIFICATION

3) FINANCIAL INFORMATION

4) SAFETY RECORD

5) OTHER INFORMATION

5) REFERENCES