Company Name:   

Contact Person:    

Address:               

City:        State:        Zip:       

Telephone:                  Fax:                

Federal ID#:              Division:  Choose one 1 - General Conditions 2 - Sitework 3 - Concrete 4 - Masonry 5 - Steel 6 - Carpentry 7 - Roofing 7 - Insulation 7 - Siding 7 - Other 8 - Doors, Windows, Hardware 9 - Painting 9 - Flooring 9 - GWB 10 - Specialties 11 - Equipment 12 - Furnishings 13 - Special Construction 14 - Elevators/Lifts 15 - Mechanical, Plumbing, HVAC 15 - Fire Protection 16 - Electrical       

Email Address:        

Scope of Work Performed:       

Type of work preferred: (commercial, residential, high end, wood, masonry, steel, etc)   

Specific Geographical Area You Work In (Example: S. NH, Lakes Region, MA, ME)  

Year Business Started:        Number of Employees:   

Form of Ownership    Sole Proprietorship    Partnership    S-Corp    C-Corp

Has Company or any of its Owners Declared Bankruptcy in last 5 years    Yes    No

Is the Company Bondable? No    Yes - Single Project Limit $ Total $ 

Have you ever failed to complete a project?                         Yes  (explain details below)     No

Have you ever failed to complete a project on time?             Yes  (explain details below)     No

Have you had a contract terminated due to performance:      Yes  (explain details below)     No

Details:

What is your current Workers' Compensation Experience Modification Rating (EMR)

Does your firm have a written safety plan?                            Yes       No

Has your firm been cited by OSHA for any Serious or Willful safety violations in the last 5 years?  Yes       No

# Jobs Run @ Time     Annual Volume $

Largest Job $   Average Job $    Smallest Job $

Current Contract Backlog:   

Do you have a Service Department?    Yes    No

Do you have 24 hour coverage?         Yes    No

5 References (Owners, Architects, and at least 2 General Contractors for work completed within the last 2 years):

Contact:    Company:   

Address:  

Telephone:    Fax: Your Contract $

Contact:    Company:   

Address:  

Telephone:    Fax: Your Contract $

Contact:    Company:   

Address:  

Telephone:    Fax: Your Contract $

Contact:    Company:   

Address:  

Telephone:    Fax: Your Contract $

Contact:    Company:   

Address:  

Telephone:    Fax: Your Contract $

3 Vendor References:

Contact:    Company:   

Address:  

Telephone: Fax: Ave. Mo. Purchase $

Contact:    Company:   

Address:  

Telephone: Fax: Ave. Mo. Purchase $

Contact:    Company:   

Address:  

Telephone: Fax: Ave. Mo. Purchase $

NOTE: NORTH BRANCH REQUIRES AN INSURANCE CERTIFICATE ON FILE INDICATING BOTH GENERAL LIABILITY AND WORKERS' COMPENSATION INSURANCE AND EXPIRATION DATES; PLEASE MAIL TO: North Branch Construction, Inc., 50 Western Avenue, Henniker, NH 03242 - NO SUBCONTRACTOR WILL BE PRE-QUALIFIED WITHOUT AN INSURANCE CERTIFICATE ON FILE.