16-Attach B - Prequalification Application.pdf

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McKinstry Subcontractor Prequalification

Please complete all requested information

Pre-qualification Application Company Name:

Trade Name (DBA):

Address Line 1:

Address Line 2:

City and State:

Vendor Contact Name:

Email:

Phone:

Business ID #, Tax ID or Federal ID/SS #:

Qualifications/License to provide Service:

(State) Contractors License #:

(State) Business License #:

SAFETY AND HEALTH PERFORMANCE

I have attached a copy of the following:

Letter from your Workers Compensation Insurance Provider of your EMR Ratings past 3 years.

Copies of your OSHA 300-A logs for the past 3 years Copies of any OSHA Citations for the past 3 year

Name:

Email:

Name / Title of who is responsible for safety at your company?

Phone:

Does your company have a written safety program?

INSURANCE & BONDING

I have attached a copy of the following:

Current copy of Liability Insurance Certificate COI w/ evidence of workers compensation coverage (Unless located and performing work in Texas) Letter from Bonding Company/Surety (statement of bonding capacity) Current W9 form *(must be the most recent version of W9

DanDeG Text Box Yes

DanDeG Text Box No

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ORGANIZATION & WORK HISTORY

Principle Owner #1: Years With Company:

Principle Owner #2: Years With Company:

Principle Owner #3: Years With Company:

How many years has your organization been in business under the current firm name?

Under what other or former names has your firm operated?:

Is your firm majority owned or controlled by any other organization? If yes, provide organization:

Form of Business: ☐ Sole Owner ☐ Partnership ☐ Corporation

Date Founded: _______________________

State of Incorporation if applicable: ______________________

What type of staff do you normally employ?

☐ Union ☐ Non-Union ☐ Leased/Temp

Average number of employees for last 3 years:

Year_________

Avg #_________

Year_________

Avg #_________

Year_________

Avg #_________

Gross Revenue for the Past Three Years: Year_________

Year_________

Year_________

Largest individual project value in past 3 years:

Name: ___________________________

Contract Value:_____________________

Average individual project value in last 3 years:

Name: ___________________________

Contract Value:_____________________

Desired project size Maximum $ Minimum $

Major current jobs in construction

Customer/location Type of Work Size $ Client contact

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Major projects past 3 years:

Customer/location Type of Work Size $ Client contact

Are there any judgments, claims or suits pending or outstanding against your company?

☐ Yes, please attach details ☐ No

Are you now or have you ever been involved in any bankruptcy or reorganization proceedings?

☐ Yes, please attach details ☐ No

Has your firm ever had a claim against a bond on which your firm stood as principle?

☐ Yes, please attach details ☐ No

Has your firm ever been denied a bond?

☐ Yes, please attach details ☐ No

REFERENCES

Provide a minimum of three references that can provide information on your company’s experience on projects of similar size and scope of work:

Name Title

Company Phone

Email

Name Title

Company Phone

Email

Name Title

Company Phone

Email

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DIVERSE BUSINESS PARTICIPATION

Is your business a certified diverse owned supplier? (Yes/No) “Certified” means currently certified by an authorized certifying body. “Owned” means at least fifty-one percent (51%) of the business?

☐ Yes ☐ No

If yes, please indicate your certification(s):

Black American Owned Woman Owned

Hispanic American Owned Service-Disabled Veteran Owned

Alaska Native Owned Veteran Owned

Native American Owned Disability Owned

Subcontinent Asian American Owned Small Disadvantaged Business

Minority Owned HubZone

LGBTQ Owned

List agencies, institutions, or organizations which have certified your firm as a diverse business:

Agency Name Contact Person Phone Approval Date Certification Number

Report Completed By:

Name:

Title:

Date:

PAGE 5 OF 5 Rev 2.0 – Jun 2021

Number Date Incorporated Changes Point of Contact

1.0 11-30-2016 Initial Release Jason Engelbrecht

1.1 02-22-2020 Released As Is Mark Brewster

2.0 6-18-2021 New Fields, and converted to fillable pdf Britin Lindberg