Subcontractor Qualification Form

Subcontractors

Subcontractor Qualification Form

Please complete the following to the best of your ability. We realize that the information requested may not apply to every subcontractor. If you are a supplier, rather than listing previous experiences on past projects, please provide recent data on projects for which you have supplied material.

COMPANY INFORMATION

Company Name:
Contact Person:
Specialty:
Title:
Address:
City:
State:
Zip:
Telephone:
Cellular Phone:
E-mail: *
NAICS:
Fax:
Pager:
Website address:
Business Status: (Please check all that apply.)
	Large Business (LB) Small Business (SB) Small Disadvantaged Business (SDB) Woman-Owned Small Business (WOSB) Minority Business Enterprise (MBE) Veteran-Owned Small Business (VOSB) Service-Disabled Veteran-Owned Small Business (SDVOSB) Historically Black College or University/Minority Institution/Tribal Universities (HBCU/MI/TU)
Number of Employees: *
Number of Years in Business: *
Annual Volume:
Please indicate if your firm is registered with any of the following Small Business Administration (SBA) programs:
	HUBZone Certification Certified Small Disadvantaged Business (SDB) Program 8(a) Certification Program - 8(a)
Certification #:
Is your firm bondable?	YesNo
Bonding Limit:
Name of Surety:
Does your firm have a Substance Abuse Program?	YesNo
Does your firm have a Safety Program?	YesNo
What is your current EMR (Experience Modification Rating)?
(Multiplier used in Workers Compensation premium calculations to recognize accident experience) PROJECT EXPERIENCE
Typical Range of Projects Performed:
Average Project: $
Smallest Project: $
Largest Project: $
Years of Experience on Job Order Contracts:
Federal:
Non-Federal:
List Five completed projects. (List any projects with Centennial first):
(1) Project Name:
Location:
Point of Contact/Phone Number:
Year work was completed:
$ Value:
(2) Project Name:
Location:
Point of Contact/Phone Number:
Year work was completed:
$ Value:
(3) Project Name:
Location:
Point of Contact/Phone Number:
Year work was completed:
$ Value:
(4) Project Name:
Location:
Point of Contact/Phone Number:
Year work was completed:
$ Value:
(5) Project Name:
Location:
Point of Contact/Phone Number:
Year work was completed:
$ Value:
Please provide at least three suppliers and/or general contractor references:
(1) Company Name:
Contact Person:
Phone Number:
(2) Company Name:
Contact Person:
Phone Number:
(3) Company Name:
Contact Person:
Phone Number:
I am interested in bidding and performing work for Centennial Contractors.
Name:
Title:
Date:
Any additional information about your firm (brochures, references, list of current projects and contract amounts, etc.) that you can provide will be appreciated.

Security

If you wish to mail the form please download this Adobe Acrobat version.