Date Submitted: Revision Date: I. Company Information /Legal Entity: Phone ( ) - Trade: Fax ( ) - Description of Trade: Address: Website Address (If Applicable): Company is a: Corporation L.L.C Partnership Sole Proprietorship Date Originated: State Federal ID# II. Organization Number of Office Staff: Number of Field Staff: Primary Contact: E-Mail Address: Company Principal(s): Financial Officer or Accountant: E-Mail Address: Estimator: E-Mail Address: Page 1 of 8
III. Licensing Information Business Classification Subcontractor Vendor Other Do you have a current Arizona Contractors license? Yes No AZ contractor s license #: Classification: Years in business: PLEASE ATTACH A COPY OF YOUR LICENSE A copy of our contractor s license is attached: Yes IV. Financial information Please provide (as an attachment) the following information: A. Your most recent internal financial statements (Balance Sheet and Income Statement), B. Your most recent Audited/Reviewed financial statements (Balance Sheet and Income Statement), C. Revenues for past three years: 1.) 2.) 3.) D. What is your forecasted revenue for the current year? Mandatory Item, Financials must be attached or delivered to DLW office for review by our CFO. Financials must be updated bi-annually prior to award of contracts. DLW uses this information strictly for pre-qualification purposes and will not disclose your personal information to any third party. V. Performance References Please provide 3 references, each a different source, for work completed in the last five years. Please include company name, project name, contact person, phone number, E-Mail, (attach additional sheet as required). Note: Contact must have direct knowledge of your performance on the listed projects. Failure to provide any requested contact information, including e-mail addresses will delay processing. GENERAL CONTRACTORS 1.) General Contractors: Project : Contact Phone: Contact Fax: 2.) General Contractors: Project : Contact Phone: Contact Fax: Page 2 of 8
Performance References (Cont.) 3.) General Contractors: Project : Contact Phone: Contact Fax: PROJECT OWNERS 1.) Project Owner: Project : Contact Phone: Contact Fax: 2.) Project Owner: Project : Contact Phone: Contact Fax: 3.) Project Owner: Project : Contact Phone: Contact Fax: SUPPLIERS 1.) Supplier: Project : Contact: E-mail: Contact Phone: Contact Fax: 2.) Supplier: Project : Contact Phone: Contact Fax: 3.) Supplier: Project : Contact Phone: Contact Fax: Page 3 of 8
VI. Project Experience List Recent Typical Project Experience (Add additional pages as required): 1.) Design-Bid-Build/Hard Bid Projects (include General Contractor, Project, Owner, Contract Amount, Percentage of Completion or Date Completed) 2.) CM@Risk Projects (include General Contractor, Project, Owner, Contract Amount, Percentage of Completion or Date Completed) 3.) Design/Build Projects (Including General Contractor, Project, Contract Amount, Percentage of Completion or Date Completed) 4.) Projects with D.L. Withers (include Project, Project Manager, Contract Amount, Percentage of Completion or Date Completed) 5.) What is your largest Project Completed to date (include General Contractor, Project, Owner, Contract Amount, Percentage of Completion or Date Completed) 6.) List three other projects that best represent the type of work your firm performs: 7.) Will you provide pre-construction services if requested? Yes No 8.) Does your company utilize 3D design? Yes No Date Implemented Software used: Page 4 of 8
VII. References Bank and Branch: Since: City: Contact: State: Zip code: Phone Number:_( ) - Bonding Can your Company provide a project specific Payment & Performance Bond? Yes No Bonding Company: Bonding Co. Rating Surety Broker/ Agent: Contact: Since: Phone: Bonding Capacity per project: Aggregate: Last Bond Issued: Date: Amount: Rate%: Insurance Do you have a current Any & All insurance on file with D. L. Withers Construction? Yes No If yes, you may skip the remainder of this section and go to Section 8. Please provide the insurance coverage limits that your company carries: General Liability: $ Umbrella (Excess Liability): $ Workers Compensation: $ Automobile: $ Can you add D.L. Withers Construction, The Owner and the Lender as additional insured on a primary and non-contributory basis? Yes No Insurance Company-General Liability: Insurance Agency: Insurance Agent: ** PLEASE ATTACH A COPY OF YOUR INSURANCE CERTIFICATE THIS DOES NOT NEED TO BE JOB SPECIFIC A copy of our insurance certificate is attached: Yes Page 5 of 8
VIII. Safety Information List your firm s Worker s Compensation Experience Modification Rate for the last 4 years (cannot be left blank). 1. Year State Rate 2. Year State Rate 3. Year State Rate 4. Year State Rate Does your firm have a written safety plan? Yes No Is your OSHA 300 log available? Yes No Does your firm have a safety orientation and training program? Yes No Does your firm conduct project safety inspections? Yes No Has your firm been cited by OSHA for a safety or health violation in the last 4 years? 1. Year Yes No 2. Year Yes No 3. Year Yes No 4. Year Yes No If yes, please explain on an attached sheet. AZ. Dust Control No. Has your firm been cited for a dust control or track-out violation in the last 4 years? 1. Year Yes No 2. Year Yes No 3. Year Yes No 4. Year Yes No If yes, please explain on an attached sheet. IX. Certifications Check Applicable Small Business Classification: SBE SDBE WOB HUB VOB SDVOB MOB Native American Other Are you certified? Yes No If yes, with who are you certified: City Of Phoenix: Other (please specify): Are you registered on the Federal Contractor Central Registration (CCR) Yes No IF CERTIFIED, PLEASE PROVIDE A COPY OF YOUR CERTIFICATION Page 6 of 8
X. Legal Information Are there currently any claims, judgments, arbitration proceedings or suits pending/outstanding against your company, officers or principals? Yes No (if yes, please explain, attach additional sheet if needed) In the last 3 years, has your company been involved in any arbitration, mediation or litigation? Yes No (if yes, please explain, attach additional sheet if needed) In the past 5 years, has your company ever failed to complete a construction contract? Yes No (if yes, Please explain, attach second sheet if needed) XI. Bidding Preferences Preferred Geographic Area: Check Location where you prefer to bid; All Arizona Northern Arizona Central Arizona Southern Arizona Other Preferred Contract Limits: Check preferred contract limit; 0-$250k 0-$500K $1 mill $5 mill +$5 mill LEED Certification: Number of LEED Certified Projects you have worked on in the past 5 years. Number of Staff that are LEED Accredited Professionals Page 7 of 8
XII. Required attachment Checklist The following attachments are referenced above and are required to complete this prequalification. Have you included: A. A copy of your Contractors License (Section 3) Yes B. Most recent Internal Financial Statements (Section 4) Yes C. Most recent audited/reviewed Financials (Section 4) Yes D. Additional pages required to complete Performance References (Section 5) Yes E. Additional pages required to complete Project Experience (Section 6) Yes F. Copy of your current Insurance Certificate (Section 7) Yes G. Additional pages required to complete Safety Information (Section 8) Yes H. Copy of your current Certification (Section 9) Yes I. Additional pages required to complete Legal Information (Section 10) Yes Signature required Signature Date Page 8 of 8