Sub Contractor Pre-Qualification Application - Meizinger Construction Services

List the corporate officers, partners, or proprietors of your firm.

Name *

Title *

Percent Ownership *

Name

Title

Percent Ownership

Name

Title

Percent Ownership

Name

Title

Percent Ownership

National Construction Trade Association Membership *

None
Associated Builders and Contractors
Associated General Contractors
Other

Company Organization

Date of Establishment *

State Where Established *

List of states/metro areas in which authorized to do work (please include license # if applicable)

State/License *

State/License

Federal ID #

Other

Contractor Parent Company Name

Contractor Parent Company President

Contractor Parent Company Address

Address Line 1

Address Line 2

City

State

Zip Code

Contractor Parent Company Phone Number

Number of Employees (office and field)

Company Profile

Type of Company

Subcontractor (Furnish & Install)
Subcontractor (Install Only)
Supplier (Materials Only)

CSI Numbers(s)

SIC Numbers(s)

Project Size (Check all that apply)

$200,000 or below
$201,000-$399,000
$401,000-$999,999
$1,000,000 or more

Geographic Work Areas (List states)

Certified Minority Business Enterprise Contractor (MBE)?

Yes
No

Certified Woman Business Enterprise Contractor (WBE)?

Yes
No

Do you have experience with LEED/Green buildings?

Yes
No

Do you have experience with Design/Build?

Yes
No

Bonding & Insurance

Insurance Company

Insurance Agent

Insurance Agent Phone Number

Bonding Company

Bonding Company Contact

Bonding Contact Telephone

Total Bonding Capacity

Current Available Bonding Capacity/Single Job

Please attach insurance certificates per sample provided.

Click or drag files to this area to upload. You can upload up to 5 files.

Do you currently carry, or can you obtain the following insurance coverage?

Workers' Compensation Statutory Maximum at Project Site Location?

Yes
No

General Liability

Yes
No

$1,000,000/$2,000,000 aggregate

Automobile Liability

Yes
No

$1,000,000/CSL

Employer Liability

Yes
No

$1,000,000/per statute

Umbrella Liability

Yes
No

$1,000,000/$1,000,000 aggregate

Safety Information

List your Experience Modification Rate (EMR) for the last three years

Year

EMR Rate

Year

EMR Rate

Year

EMR Rate

List the Number of OSHA recordable incidents over the prior three years

Data available at www.osha.com

Year

Number

Year

Number

Year

Number

Do you have a written Safety Program?

Yes
No

Are all employees trained in safety requirements?

Yes
No

Do you have a Company Safety Director or other Safety Professionals on Staff?

Yes
No

Sales Information

Year 1

Max. Contract Value Completed (Yr. 1)

Annual Company Revenue

Current Yr. Company Workload

Year 2

Max. Contract Value Completed (Yr. 2)

Annual Company Revenue

Current Yr. Company Workload

Year 3

Max. Contract Value Completed (Yr. 3)

Annual Company Revenue

Current Yr. Company Workload

Vendor References

Please list three vendor references who you have bought materials from in the last year.

Reference 1 Name

Reference 1 Address

Address Line 1

Address Line 2

City

State

Zip Code

Reference 1 Contact Name

Reference 1 Contact Phone Number

Reference 2

Reference 2 Name

Reference 2 Address

Address Line 1

Address Line 2

City

State

Zip Code

Reference 2 Contact Name

Reference 2 Contact Phone Number

Reference 3

Reference 3 Name

Reference 3 Address

Address Line 1

Address Line 2

City

State

Zip Code

Reference 3 Contact Name

Reference 3 Contact Phone Number

General Contracting References

Please list three general contractors with whom you have worked for in the last year.

Reference 1 Name

Reference 1 Address

Address Line 1

Address Line 2

City

State

Zip Code

Reference 1 Contact Name

Reference 1 Contact Phone Number

Reference 2

Reference 2 Name

Reference 2 Address

Address Line 1

Address Line 2

City

State

Zip Code

Reference 2 Contact Name

Reference 2 Contact Phone Number

Reference 3

Reference 3 Name

Reference 3 Address

Address Line 1

Address Line 2

City

State

Zip Code

Reference 3 Contact Name

Reference 3 Contact Phone Number

Bank References

Please list two banks with whom you have worked with in the last 2 years.

Reference 1 Name

Reference 1 Address

Address Line 1

Address Line 2

City

State

Zip Code

Reference 1 Contact Name

Reference 1 Contact Phone Number

Reference 2

Reference 2 Name

Reference 2 Address

Address Line 1

Address Line 2

City

State

Zip Code

Reference 2 Contact Name

Reference 2 Contact Phone Number

Please complete requested information on company's recent major contstruction projects either completed or in progress; or attach list.

Attach list of recent projects, or fill out fields below.

Click or drag files to this area to upload. You can upload up to 5 files.

Project 1

Name of Project

Client/Owner

General Contractor

Location

Contract Value

Description of Work Being Performed

Architect/Engineer

General Contractor Contact Name

General Contractor Contact Phone Number

Completion (Planned) Date

Project 2

Name of Project

Client/Owner

General Contractor

Location

Contract Value

Description of Work Being Performed

Architect/Engineer

General Contractor Contact Name

General Contractor Contact Phone Number

Completion (Planned) Date

Project 3

Name of Project

Client/Owner

General Contractor

Location

Contract Value

Description of Work Being Performed

Architect/Engineer

General Contractor Contact Name

General Contractor Contact Phone Number

Completion (Planned) Date

Project 4

Name of Project

Client/Owner

General Contractor

Location

Contract Value

Description of Work Being Performed

Architect/Engineer

General Contractor Contact Name

General Contractor Contact Phone Number

Completion (Planned) Date

Have you failed to complete awarded work or been terminated for cause? Do you have any judgements, claims, arbitrations, suits, or liens currently against your organization, or have you any had bankruptcies or reorganizations in the last ten years? *

Yes
No

Within the past five years, has your company or any of the individuals identified in the Company Information Section of this form been subject of any criminal indictment or judgment of conviction for any business-related conduct constituting a crime under state or federal law? *

Yes
No

Within the past five years, has your company or any of the individuals identified in the Company Information Section of this form been subject of any federal or state suspension or disbarment? *

Yes
No

Within the past five years, has your company or any of the individuals identified in the Company Information Section of this form been subject of any formal proceeding or consent order with a state or federal agency involving a violation of state or federal contracting or environmental laws? *

Yes
No

Credit Authorization

The submitter of this prequalification form authorizes contacting any of the references given on this form and further authorizes each of those representatives to disclose any and all information the reference may have regarding the submitter. Also, the submitter authorizes the release of credit information including a credit report or other sources of credit information and this authorization shall be without expiration. Do you agree to these terms? *

Yes
No

Dunn & Bradstreet #

Signature of Officer *

Date *

Return Completed Form Attn

Title

Company

Fax

Company Information

List the corporate officers, partners, or proprietors of your firm.

Company Organization

List of states/metro areas in which authorized to do work (please include license # if applicable)

Company Profile

Bonding & Insurance

Do you currently carry, or can you obtain the following insurance coverage?

Safety Information

List your Experience Modification Rate (EMR) for the last three years

List the Number of OSHA recordable incidents over the prior three years

Sales Information

Year 1

Year 2

Year 3

Vendor References

Reference 2

Reference 3

General Contracting References

Reference 2

Reference 3

Bank References

Reference 2

Please complete requested information on company's recent major contstruction projects either completed or in progress; or attach list.

Project 1

Project 2

Project 3

Project 4

Credit Authorization

Join Our Team - Great Opportunities Available