SUBCONTRACTOR PRE-QUALIFICATION FORM Today’s Date (MO/DAY/YEAR): / / Person Completing Form: Company Information Company Name: Company Website: President/Owner/Partner Name: Qualifier Name/Title: Address/City/State/ZIP: Phone: Fax: FL State License #: Contact Email: National Construction Trade Association Membership: Associated Builders and ContractorsAssociated General ContractorsOther: Structure of Company CorporationSole ProprietorLLCPartnershipGeneral or LimitedJoint Venture Date of Establishment State Where Established: List of states/metro areas in which authorized to do work (please include license # if applicable): FL FL(Other) Federal ID # Other Contractor parent company (company name/president/address/phone): #of Employees (office and field): Company Profile Type of Company: Subcontractor (Furnish & Install)Subcontractor (Install Only)Supplier (Materials Only) CSI Numbers(s): SIC Number(s): Project Size: (Check all that apply) $250,000 or below$251,000– $499,000$500,000 – $999,999$1,000,000 or more Types of Projects: (Check all that apply) SchoolsGovernmentHealthcareHospitalityLodgingIndustrialOfficeRestaurantRetailOther Geographic Work Areas: (Check all that apply or list states) Central, FLSouth, FLNorth, FLOTHER Certified Minority Business Enterprise Contractor (MBE)? yesno Certified by: Certified Woman Business Enterprise Contractor (WBE)? yesno Certified by: Do you have experience with LEED/green buildings? yesno Bonding & Insurance Name of Bonding Agency: Relationship Officer: Phone: Fax: Bonding Company: A.M. Best Rating of Bonding Company: Bonding Capacity Single Job: $ Bonding Capacity Aggregate: $ Please attach workers comp and general liability insurance certificates What is your workers comp EMR (experience modification rate) for the last 3 years? Year: EMR: Year: EMR: Year: EMR: Please attach copy of previous year’s OSHA 300 form Trade References: Please list three trade/vendor references with whom you have worked for in the last year. Name: Address: City/State/ZIP: Contact: Contact Phone Number/Cell Number: Name: Address: City/State/ZIP: Contact: Contact Phone Number/Cell Number: Name: Address: City/State/ZIP: Contact: Contact Phone Number/Cell Number: General Contractor References Please list three general contractors with whom you have worked for in the last year. Name: Address: City/State/ZIP: Contact: Contact Phone Number/Cell Number: Name: Address: City/State/ZIP: Contact: Contact Phone Number/Cell Number: Name: Address: City/State/ZIP: Contact: Contact Phone Number/Cell Number: Credit Authorization The submitter of this prequalification form authorizes contacting any of the references given on this form and further authorizes each of those representatives to disclose any and all information the reference may have regarding the submitter. Also, the submitter authorizes the release of credit information including a credit report or other sources of credit information and this authorization shall be without expiration. Do you agree to these terms? yesno Dunn & Bradstreet # Signature Date: Work in progress Please complete requested information on company’s recent major construction projects either completed or in progress; or attach list. (Please make additional copies as needed). Amount of work under contract: Amount of that work not yet completed: Name of Project Client/Owner General Contractor Location Contract Value Description of Work Being Performed Architect/Engineer General Contractor Contact Phone Number Completion (Planned) Date Name of Project Client/Owner General Contractor Location Contract Value Description of Work Being Performed Architect/Engineer General Contractor Contact Phone Number Completion (Planned) Date Add Project+ Name of Project Client/Owner General Contractor Location Contract Value Description of Work Being Performed Architect/Engineer General Contractor Contact Phone Number Completion (Planned) Date Name of Project Client/Owner General Contractor Location Contract Value Description of Work Being Performed Architect/Engineer General Contractor Contact Phone Number Completion (Planned) Date Add Project+ Name of Project Client/Owner General Contractor Location Contract Value Description of Work Being Performed Architect/Engineer General Contractor Contact Phone Number Completion (Planned) Date Name of Project Client/Owner General Contractor Location Contract Value Description of Work Being Performed Architect/Engineer General Contractor Contact Phone Number Completion (Planned) Date
