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Test Subcontractor Form
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Name of Company
*
Office Address
*
123 Example St., City, State, Zip Code
Date
*
Emergency Phone
Fax Number
*
Email Address
*
Name of Principal(s)
*
Home Address or PO Box
*
123 Example St., City, State, Zip Code
Home Phone
*
Emergency Phone
Type of Services Available
*
What types of projects do you specialize in?
*
Is your business seasonal?
*
Yes
No
If yes, please choose which months are your high and low months from the dropdowns below.
High Month
January
February
March
April
May
June
July
August
September
October
November
December
Low Month
January
February
March
April
May
June
July
August
September
October
November
December
Size of Company (Average Gross Sales)
*
Average Contract Size
*
How many years has your company been in business?
*
Have you always been at the same location?
*
If no, please state how many years you have been at the current location.
Number of Employees (Maximum for Last Year)
*
How often is your payroll paid?
*
Weekly
Bi-Monthly
Monthly
Do your employees belong to a union?
*
Yes
No
If yes, what is the name of the union?
Minority Business Enterprise?
*
Yes
No
Company Banks at:
*
Bank Address
*
123 Example St., City, State, Zip Code
Contact Name
*
Phone Number
*
Can you provide a performance and payment bond?
*
Yes
No
If yes, what is the maximum bond line and rate (%)?
*
First
Last
Bonding Company
Address
123 Example St., City, State, Zip Code
Agent
Phone Number
Can your company provide liability insurance?
*
$1,000,000
$2,000,000
Other
If other, please list amount.
Please list other states your company is licensed in.
*
For example: CA, AZ, TX, or None
Please list any and all license numbers.
How far will you travel for work (miles)?
*
Is your company certified or pre-qualified to do
State
Federal
Municipal Work
Please select all that apply.
Public Works License Number
Federal Tax Identification Number
*
Company Name
*
Business Physical Address
*
123 Example St., City, State, Zip Code
Business Mailing Address
*
123 Example St., City, State, Zip Code
Contact Person
*
Phone Number
*
Company Name
*
Business Physical Address
*
123 Example St., City, State, Zip Code
Business Mailing Address
*
123 Example St., City, State, Zip Code
Contact Person
*
Phone Number
*
Company Name
*
Business Physical Address
*
123 Example St., City, State, Zip Code
Business Mailing Address
*
123 Example St., City, State, Zip Code
Contact Person
*
Phone Number
*
Company Name
*
Business Physical Address
*
123 Example St., City, State, Zip Code
Business Mailing Address
*
123 Example St., City, State, Zip Code
Contact Person
*
Phone Number
*
Company Name
*
Business Physical Address
*
123 Example St., City, State, Zip Code
Business Mailing Address
*
123 Example St., City, State, Zip Code
Contact Person
*
Phone Number
*
Company Name
*
Business Physical Address
*
123 Example St., City, State, Zip Code
Business Mailing Address
*
123 Example St., City, State, Zip Code
Contact Person
*
Phone Number
*
Has your company ever gone
*
Bankrupt
Reorganized
If so, what year?
Has your company been involved in any lawsuit in the last 5 years?
*
Yes
No
If yes, please provide an explanation below.
Paragraph Text
How do you feel your company rates in terms of quality workmanship?
*
Very High
Above Average
Average
Approximately what percentage of jobs bid is awarded to your company?
*
Do you provide written confirmation of bid figures?
*
Yes
No
Do you normally work by contract?
*
Yes
No
List your firm's workers' compensation Interstate Experience Modification Rate for the three most recent years.
*
Last Year
Single Line Text
Two Years Ago
Single Line Text
Three Years Ago
Number of lost workday cases:
*
Please use your last year's OSHA No. 300 log to answer.
Number of fatalities:
*
Please use your last year's OSHA No. 300 log to answer.
Do you have a written Accident Prevention Program?
*
Yes
No
Have you ever worked on a LEED Project?
*
Yes
No
If yes, please list project info below.
Project Name
Address
123 Example St., City, State, Zip Code
Primary Contact
Phone Number
Project Name
Address
123 Example St., City, State, Zip Code
Primary Contact
Phone Number
Project Name
Address
123 Example St., City, State, Zip Code
Primary Contact
Phone Number
Please type your full name to E-Sign this PreQualification Form.
*
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Last
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*
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