Type of Company
Corporation |
Partnership |
Sole Proprietorship
Significant Changes
If there have been any significant changes to the ownership, management or structure of your business within the last three years, please explain:
Small / Minority / Disadvantaged Business Certification
Are you a certified small, minority or disadvantaged business?
No |
Yes
If yes, provide all certifying agency(s), certification type and corresponding certification number:
License
State License Number
a. List Florida Counties where company is licensed
b. List other States where your company is licensed
Number of years your company has been in business
Years in business under present name
Number of Employees
Scope of work performed with your own forces
Percentage of work performed by own forces
Completed Projects
Representative projects completed in the last five (5) years.
Name of Project/Location
Contracting Company
Contact Name/Phone
Contract Amount %
Bonded
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Current Projects
Representative projects currently under construction.
Name of Project/Location
Contracting Company
Contact Name/Phone
Contract Amount %
Bonded
Yes
No
Yes
No
Yes
No
Yes
No
Do you perform work out of your geographic area?
Yes |
No If so, where?
In what Counties do you work?
In what States do your work?
Largest project completed to date ($)
Date Completed
Location of largest project
Size/type of project your company prefers (sf/stories/etc.)
Contact
Safety
Worker's Compensation Insurance Modifier for the past three years?
Current 1st Prior Year
2nd Prior Year
Do you have a written safety program and/or policies?
Yes |
No
Do you have a written drug policy?
Yes |
No
Do you employ a full-time site safety professional?
Yes |
No
In the past three years, have you been cited for any serious (OSHA) safety violation?
Yes |
No
If yes, please provide an explanation below, including the dates, violation types, descriptions and inspection numbers of each violation.
Insurance
General Liability Limits
$ per occurrence $
aggregate
Insurance Company
Insurance Company Address
Agent Name
Agent Phone Number
Bonding Capacity
Is your company bondable?
Yes, Limits
|
No
Surety Company
Agency Company
Agent Contact
Agent Phone
Bank & Credit References
Do you have a line of credit from any lending institution?
Yes |
No
Bank References Include name, branch, contact, and telephone number
Dunn & Bradstreet Number
I hereby authorize release of the above referenced information
Client References
Project Name
General Contractor and Contact
Telephone and Fax Number
Supplier References
List suppliers you currently do business with
Supplier
Contact
Telephone
Fax
Performance and Claim History
Have you ever failed to complete a project?
If yes, please provide a detailed explanation below:
Yes |
No
Have you ever been terminated?
If yes, please provide a detailed explanation below:
Yes |
No
Have you ever defaulted, or been declared in default of, a contract?
If yes, please provide a detailed explanation below:
Yes |
No
Have you been involved in bankruptcy or re-organization?
Yes |
No
Are there, of have there been, any claims or suits (including arbitration or administrative proceedings) by or against you in relation to your performance or compliance with applicable laws on a construction project, either pending or resolved, with the last five years?
If yes, please provide a detailed explanation below:
Yes |
No
Are there any pending or unpaid debts or judgments against you?
Yes |
No
Have you ever been barred from bidding any state or federal public construction work?
If yes, please provide a detailed explanation below:
Yes |
No
Have you ever been barred from bidding any national retail accounts?
If yes, please provide a detailed explanation below:
Yes |
No
Have you ever been convicted of, or entered a plea of guilty, or nolo contender, for criminal violations relating to, its business or the budding or performance of a construction project?
If yes, please provide a detailed explanation below:
Yes |
No
Have you ever been found civilly liable for any criminal offense or civil action involving forgery, bribery, falsification or destruction or records, or other similar offenses arising out of its business or the bidding or performance of a construction project?
If yes, please provide a detailed explanation below, including the case number, docket number, jurisdiction, and case description:
Yes |
No
I hereby certify that all information provided in this form is true and correct to the best of my knowledge.
Applicant Name*
All Information provided in this pre-qualification statement would be kept confidential.
