General Information:

Date of Application:

Complete Name of Soliciting Firm:

Previous Names (if any):

Date of Incorporation (if applicable):

Address:

Phone Number:

fax Number:

Email Address:

Dunn & Bradstreet Reference #:

Federal Tax ID#:

Years in Business (present name):

Scope of Work Desiring to Bid:

Percentage of Work to be Performed with Own Forces:

Union Affiliations (local or national):

Contractor Licensing Number:

Bonding Information:

Is your organization bondable? YesNo

If yes, Please complete the following:

Surety Company:

Name & Address of Agent:

Phone Number of Agent:

Bonding Capacity:

Value of Work Presently Bonded:

Bonding Limit for a single Project:

Bonding Rate:

Are you willing & able to provide a bond for this project if required? YesNo

Insurance Information:

Insurance Company & Address:

Agent Company & Address:

Agent Contact:

Agent Phone Number:

Minimum Required Coverages:

1. Worker's Compensation and Employer's Liability - minimum statutory limits or $1,000,000 each occurrence,

2. Comprehensive General Liability - minimum $1,000,000, combined single limit, each occurrence, $2,000,000 general aggregate,

3. Comprehensive Automobile Liability covering owned, non-owned and leased vehicles for a minimum of $1,000,000 combined single limit for bodily injury, death or property damage, each occurrence, $2,000,000 general aggregate,

4. Professional Liability - minimum $1,000,000 each occurrence, $2,000,000 general aggregate, and

5. Pollution Legal Liability in the amount of $1,000,000 each occurrence, $2,000,000 general aggregate.

Safety:

Do you have a written company-wide safety program? YesNo

If yes, is the program compliant with:

Does your company require employees to be:

Do you have a Drug Free Workplace policy in place? YesNo

Have you had any OSHA fines in the last 3 Yrs? YesNo

Have you had any jobsite fatalities within the last 3 yrs? YesNo

If yes to either of the last 2 questions above, please explain:

Please List your Worker’s Compensation Experience Modification Rate (EMR) for each of the last three (3) Years:

Years

Years

Years

Note: If EMR Average for the last 3 years is over 1.0, please submit an OSHA 200 log for each year.

Minority/E.E.O. Compliance:

Is your organization in compliance with all EEO requirements? YesNo

Does your company have an Affirmative Action Plan? YesNo

Is your organization a certified minority or small business contractor? YesNo

List agencies with whom certified:

Experience & References:

Work Performed: UnionNon-UnionPrevailing Wage

NAICS Code:

Trade/Division:

If yes, Federal Department:

Federal Experience: YesNo

If yes Federal Department:

Federal Sites:

Number of years’ experience your firm has had in trade being bid: years

Please list the last three (3) projects completed by your firm :
Note: Please do not include projects for which your firm is not yet begun or has just started.

Geographic Areas:

Work Performed:

Areas willing to work:

Project #1:

Project Name :

Location:

Total Value of Project:

General Contractor/Owner:

G.C./Owner Contact:

G.C./Owner Phone Number:

Work Performed:

Completion Date:

Project #2:

Project Name :

Location:

Total Value of Project:

General Contractor/Owner:

G.C./Owner Contact:

G.C./Owner Phone Number:

Work Performed:

Completion Date:

Project #3:

Project Name :

Location:

Total Value of Project:

General Contractor/Owner:

G.C./Owner Contact:

G.C./Owner Phone Number:

Work Performed:

Completion Date:

Please list the 3 most significant projects completed in the last five (5) years:

Project #1:

Project Name :

Location:

Total Value of Project:

General Contractor/Owner:

G.C./Owner Contact:

G.C./Owner Phone Number:

Work Performed:

Completion Date:

Project #2:

Project Name :

Location:

Total Value of Project:

General Contractor/Owner:

G.C./Owner Contact:

G.C./Owner Phone Number:

Work Performed:

Completion Date:

Project #3:

Project Name :

Location:

Total Value of Project:

General Contractor/Owner:

G.C./Owner Contact:

G.C./Owner Phone Number:

Work Performed:

Completion Date:

Financial Statement

Please complete the following information or provide a copy of your last certified yearend financial statement under separate cover:

Date of the information that follows:

ASSETS

Cash:

Accounts Receivable Trade:

Inventory:

Prepaid Expenses:

Total Current Assets:

Leasehold Equipment:

Mobile Equipment:

Plant Equipment:

Total Plant & Equipment:

Less Accum., Depre., & Amort.:

Net Plant & Equipment:

Other Assets (Please describe):

LIABILITIES

LIABILITIES & STOCKHOLDER’S EQUITY

Current Liabilities

Accounts Payable Trade:

Notes Payable:

Accrued Payroll & Taxes:

Accrued Expenses:

TOTAL LIABILITIES:

Stockholder’s Equity

Common Stock:

Paid in Capital:

Retained Earnings

Current Earnings:

TOTAL STOCKHOLDER’S EQUITY:

TOTAL LIABILITIES & STOCKHOLDER’S EQUITY:

Please provide net total billings (contract volume) for your firm over the past three (3) fiscal years:

2011 total billings to date:

2010 total billings:

2009 total billings:

Current backlog of work for next 12 months (List total $ value):

Has your firm failed to complete any contract: YesNo

Has your firm been involved in Bankruptcy or reorganization? YesNo

Has your firm been involved in any litigation or claims? YesNo

Has your firm had liquidated damages filed against it? YesNo

Has your firm been involved with any claims? YesNo

Has your firm been involved with any construction liens? YesNo

If yes to any of the above questions, please explain:

By executing this document, you acknowledge that all information contained herewith is true, complete, and correct, and that you accept all of the terms and conditions contained within this document without exception.

Signature of Person completing form:

Typed Name:

Title:

Date: