EmailMe Form - DowCon, LLC Subcontractor Pre-Qualification Form

Name of Project *

Contract Amount

Legal Business Name *

d/b/a Name (if different)

Mailing Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Physical Address (if different)

Street Address City State / Province / Region Postal / Zip Code Country / Region

Office Phone *

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

Office Fax

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

ONSITE CONTACT INFORMATION

Contact *

First Last

Title *

Email

Phone *

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

EMERGENCY CONTACT INFORMATION

Contact

First Last

Title

Email

Phone

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

ORGANIZATION

Business Type: *

State Founded:

Date Founded:

Check if you have Missouri Certification for:

Other names which firm has done business as:

Change of ownership in the past 2 years or planning change within the next 90 days?

YES

NO

If yes, Please explain:

KEY PROJECT EMPLOYEES

Name and Title:

OSHA 10:

Name and Title:

OSHA 10:

Name and Title:

OSHA 10:

Name and Title:

OSHA 10:

Name and Title:

OSHA 10:

LICENSED / AREAS OF OPERATION

List trade(s) or services your firm is licensed or certified to provide: *

Type of License / Certification:

License / Certification Number:

Have any of the License listed been denied or revoked?

YES

NO

If yes, Please explain:

Ever had a complaint filed against your license or firm?

YES

NO

If yes, Please explain:

Company geographic area of operation:

Consider working outside of your geographic area?

YES

NO

If yes, How far:

INSURANCE INFORMATION

INSURANCE COMPANY: *

Phone

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

Workers Compensation limit of liability:

General Liability limit of liability:

WORK EXPERIENCE

Average project size? (Dollar Amount)

Preferred job size? (Minimum)

$ Dollars . Cents

Preferred job size? (Maximum)

$ Dollars . Cents

Amount and year of largest job completed?

Failed to complete work awarded or been terminated for cause? (past 3 years)

YES

NO

If yes, Please explain:

Liquid damages assessed against you or your firm? (past 3 years)

YES

NO

If yes, Please explain:

Investigated or found to have violated any labor laws? (past 3 years)

YES

NO

If yes, Please explain:

Investigated or found to have violated state, Local or federal environmental protection laws? (past 3 years)

YES

NO

If yes, Please explain:

Judgement, claims, arbitration, suits, or pending proceedings against firm. officers, principals or owners?

YES

NO

If yes, Please explain:

Firm filed any lawsuits or requested mediation with regards to construction contracts? (past 3 years)

YES

NO

If yes, Please explain:

Has your surety ever finished one of your construction projects?

YES

NO

If yes, Please explain:

BACKLOG INFORMATION

Dollar amount of your backlog as of today?

Projects that make up today's backlog:

Dollar amount and number of projects anticipated completing in the next 3 months?

Dollar amount and number of projects anticipated starting in the next 3 months?

PROJECT REFERENCE INFORMATION

Project #1

General Contractor: *

Project Name:

Contract Amount

GC Contact Person

Contact Email

Contact Phone

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

Project #2

General Contractor: *

Project Name:

Contract Amount

GC Contact Person

Contact Email

Contact Phone

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

Project #3

Project Name:

Contract Amount

GC Contact Person

Contact Email

Contact Phone

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

SUPPLIER REFERENCE INFORMATION

SUPPLIER #1

Supplier Name: *

Contact Person:

Contact Email

Contact Phone

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

SUPPLIER #2

Supplier Name:

Contact Person:

Contact Email

Contact Phone

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

SUPPLIER #3

Supplier Name:

Contact Person:

Contact Email

Contact Phone

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

FINANCIAL INFORMATION

2014 Est Revenue:

2013 Total Revenue:

2012 Total Revenue:

2011 Total Revenue:

Liens filed against your firm by any individual, commercial firm or Government Agency? (past 3 years)

If yes, Please explain:

Filed bankruptcy or voluntary reorganization? (past 3 years)

If yes, Please explain:

Considering a bankruptcy or reorganization within next 6 months?

If yes, Please explain:

SAFETY INFORMATION

Employ a full time safety representative or consultant?

YES

NO

Any job site fatalities in the past 3 years?

YES

NO

If yes, Please explain:

Any OSHA fines in the past 3 years?

YES

NO

If yes, Please explain:

Provide OSHA training for all employees?

YES

NO

Have a written safety policy or program?

YES

NO

Have a written drug / alcohol testing policy or program?

YES

NO

If requested, will you review your loss control system with us?

YES

NO

CERTIFICATION AND AUTHORIZATION

This application must be signed by an Officer, Principle or Owner of your firm.

I certify that to the best of my knowledge the information given in response to each question and in the requested documentation is full, complete and accurate.

I authorize DowCon,LLC to contact any entity named in this application, or in the requested documentation which I have provided, for the purposes of verifying the information supplied.

I acknowledge that DowCon,LLC may, by means it deems appropriate, determine the accuracy and truth of the statements made in this application and the requested documentation that I have provided.

I recognize that all of the information submitted is for prequalification purposes only. Additional or different standards are required for each job or project awarded by DowCon,LLC. Those standards and requirements are set forth in each invitation to bid. Prequalification in no way insures the award of contract work.

I RECOGNIZE THAT A MATERIAL FALSE STATEMENT AND/OR OMISSION MADE IN CONNECTION WITH THIS APPLICATION IS SUFFICIENT CAUSE FOR DISQUALIFICATION OF THE APPLICATION BY DowCon,LLC.

Date Time

MM / DD / YYYY

Signature *

Clear

Digital Signature

APPLICATION COMPLETION CHECKLIST

Please take a moment to go through the checklist and ensure that you have all information required

Current Certificate of Insurance

List of Trade organizations which you are member

Complete Application with ALL Questions answered

Answer for any question with explination requested

Certification and Authorization completed by Owner

Certificate of Insurance