Please provide the following information completely and accurately.
Today's Date

MM		/
DD		/
YYYY
Company Name
Contact Name

First
Last
Mailing Address

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Physical Address

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Phone Number

###		-
###		-
####
Fax Number

###		-
###		-
####
Email

COMPANY INFORMATION

Florida Contractor License Number
Geographic Area of Business Interest
Years in Business Under Present Name
Work Specialty
Years Performing Work Specialty
Work Now Under Contract ($)
Work in Place Last Year ($)
Approximate Value of Equipment Owned by Company ($)
Percent of Work Performed by Own Forces (%)
Total Number of Permanent Staff Employed by Company
Number of Office Staff
Number of Field Personnel
Average Work Force for the Past Five Years
Is Company in Compliance with EEO Requirements?
 YES 
 NO 
Has Company Ever...
 Failed to Complete a Contract? 
 Been Involved in Bankruptcy or Reorganization? 
 Had Pending Judgement Claims or Suits? 
 Been Assessed Liquidated Damages on any Project? 
Check All That Apply.
Does Company Have a Current Rating with Dun & Bradstreet?
 YES 
 NO 
If Yes, What is Your D&B Rating?

BONDING INFORMATION

Value of Work Presently Bonded ($)
Total Bonding Capacity ($)
Bonding Surety
Bonding Agent
Phone Number

###		-
###		-
####

INSURANCE INFORMATION

Insurance Agent
Phone Number

###		-
###		-
####
General Liability Insurance Policy Number
Expiration Date

MM		/
DD		/
YYYY
Worker's Compensation Insurance Policy Number
Expiration Date

MM		/
DD		/
YYYY

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