Date:

Company Information

Company Name:

Street:

City: State: AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY Zip Code:

Office: - -

Fax: - -

Mobile: - -

Beeper: Type: Digital Analog

E-mail: Web Page:

Does your company use the Nextel phone system? Yes No

Owner(s):

Estimator(s):

Year Organized:

Work you typically self-perform:

Number of Full-Time Employees:

Previous Year's Sales:

Do you have a Written Safety Program? Yes No

Type of Business Enterprise:

Disadvantaged
Minority
Woman Owned
Handicap Owned
Small Business
Historically Underutilized
Other:

Has formal certification of the above been made? Yes No

If yes, by what agency? Date of certification:

Are you prohibited from performing City, State, or Federal work? Yes No

Has your organization ever failed to complete any work awarded to it? Yes No

Are there any judgments, claims, arbitration porceedings, or suits pending or outstanding against your organization or officers? Yes No

If yes, explain:

Has your organization filed any law suits or requested arbitration with regards to contruction contracts within the last five years? Yes No

If yes, explain:

Within the last five years, has any officer or principal of your organization ever been an officer or principal of another organization when it failed to complete a construction contract? Yes No

Has your organization, or any predecessors to your organization, ever files a petition seeking relief in bankruptcy court? Yes No

Insurance Information

Bonding Insurance:

Company:          Contact:

Telephone:         Limits:   

Commercial Liability Insurance:

Company:          Contact:

Telephone:         Limits:   

Worker's Compensation Insurance:

Company:          Contact:

Telephone:         Limits:   

Commercial Auto Insurance:

Company:          Contact:

Telephone:         Limits:   

Commercial Umbrella Insurance:

Company:          Contact:

Telephone:         Limits:   

Contract and Trade Information

Largest Trade References:

1. Company:           Contact:

    Telephone:         Amount: 

2. Company:           Contact:

    Telephone:         Amount: 

3. Company:           Contact:

    Telephone:         Amount: 

Largest Contracts in Last 12 Months:

1. Project:       

    Contractor:           Contact:

    Telephone:            Amount:

2. Project:       

    Contractor:           Contact:

    Telephone:            Amount:

3. Project:       

    Contractor:           Contact:

    Telephone:            Amount:

Last 3 Projects:

Last Project:

Project:       

Contractor:           Contact:

Telephone:            Amount:

Second Last Project:

Project:       

Contractor:           Contact:

Telephone:            Amount:

Third Last Project:

Project:       

Contractor:           Contact:

Telephone:            Amount:

Application Completed by:

Name:   Title:     Telephone: