SUBMIT TO: ADDRESS: 9571 Hwy 264 Alt West P. O. Box 127 I. GENERAL INFORMATION Company Name: Contact Name: Address: Telephone Number: Fax Number: E-Mail: Company Description: Corporation Partnership Individual Joint Venture LLC/PLLC Other II. BACKGROUND INFORMATION 1. How many years has your company been in business? 2. List any other/former names our company has operated under: Page 1
3. If you selected Corporation as your Company Description, answer this section. a. Date of incorporation: b. State of incorporation: c. President s name: d. Vice-President s name(s): e. Secretary s name: f. Treasurer s name: g. Shareholder s name: 4. If you selected Partnership as your Company Description, answer this section. a. Date of organization: b. Type of partnership (if applicable): c. Name(s) of general partner(s): 5. If you selected Individual as your Company Description, answer this section. a. Date of organization: b. Name of owner: 6. If you selected LLC/PLLC as your Company Description, answer this section. a. Date of organization: b. Name(s) of member(s): c. Name of manager (unless member-managed): 7. If you selected Other as your Company Description, answer this section. a. Date of organization: b. General Description: c. Name(s) of the principal(s): 8. Does your firm qualify as either a Minority Business Enterprise or a Historically Underutilized Business? Yes No Page 2
a. If yes, please list category / qualification information: AVAILIBILITY 1. What is the dollar value of the work you have under contract at this time? a. What percentage of this work is in place? b. What percentage of this work is underway? c. What percentage of this work has yet to start? 2. What is your company s average (over the past three years) yearly sales volume? III. REFERENCES 1. Current Project References a. Provide a list of your company s major projects that are currently under contract. Provide the following for each project: (a) Project Name; (b) Architect, Contact Name & Contact Number; (c) Owner, Contact Name & Contact Number; (d) Contract Amount; & (e) Performance & Payment Bond Provided or Not Provided. (Provide this list as Attachment A Current Project References.) 2. Past Project References a. Provide a list of three projects completed within the last six years that are similar in size and nature to the project this Submittal is for. Provide the following for each project: (a) Project Name; (b) Architect Contact Name & Contact Number; (c) Owner, Contact Name & Contact Number; (d) Contract Amount; &(e) Performance & Payment Bond Provided or Not Provided. (Provide this list as Attachment B Past Project References.) 3. Bank Reference a. Name of Bank: b. Contact Name: Page 3
c. Contact Number: d. Type of Account: 4. Bonding References a. Bonding Agent 1. Company Name: 2. Contact Name: 3. Contact Number: b. Surety 1. Company Name: 2. Contact Name: 3. Contact Number: IV. SAFETY 1. Name of Safety Director or Coordinator: Contact Information: 2. Provide a copy of your written safety policy. 3. Have you had any OSHA violations in the past 3 years? Yes No If yes, explain: List the amount or any fines: 4. Provide a copy of your OSHA 300 Log for the past 3 years. 5. List your modification factor for the last 3 years. Page 4
V. OTHER INFORMATION 1. Has your company, or any affiliated company, or any of its principles ever petitioned for bankruptcy, failed in business, closed a business, defaulted a contract, or failed to complete a contract? Yes No (If yes, please provide details in Attachment D Other Information) 2. Is your company, or any affiliated company, or any of its principles directly involved with any outstanding/pending arbitration proceedings or lawsuits? Yes No (If yes, please provide details in Attachment D Other Information) 3. Has your company, or any affiliated company, or any of its principles initiated any arbitration proceedings or filed a lawsuit to resolve a construction contract claim within the last three years? Yes No (If yes, please provide details in Attachment D Other Information) Page 5
Attachment A Current Project References: ( ) Pages Page 6
Attachment B Past Project References: ( ) Pages Page 7
Attachment B1 Relevant Project References: ( ) Pages Page 8
Attachment C Other Information ( ) Pages (Any information not specifically called for elsewhere should be included in Attachment C.) Page 9