| Company Name: |
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| Contact Person: |
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| Address: |
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| City: |
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State: |
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Zip: |
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| Telephone: |
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Fax: |
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| Federal ID#: |
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Division: |
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| Email Address: |
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| Scope of Work Performed: |
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Type of work preferred: (commercial, residential, high
end, wood, masonry, steel, etc)
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Specific Geographical Area You Work In (Example: S. NH,
Lakes Region, MA, ME)
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| Year Business Started:Number of
Employees: |
| Web Page:
MBE/WBE/DBE:
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| 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 |
No
Is the Company Bondable?
No
Yes - Single Project Limit $
Total $
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| Have you ever failed to complete a project?
Yes (explain below)
No |
| Have you ever failed to complete a project on time?
Yes (explain below)
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| No
Have you had a contract terminated due to performance:
Yes (explain below)
No |
| Details:
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| What is your current Workers' Compensation Experience
Modification Rating (EMR)
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| Does your firm have a written safety plan?
Yes
No |
| Does your firm have a written Hazardous Communications Program?
Yes
No |
| Has your firm been cited by OSHA for any Serious,
Willful or Repeat Safety Violations in the last 5 years?
Yes
No (if yes, explain below)
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Have you participated in any legal, arbitration or
mediation proceedings in the last five years?
Yes
No
If Yes, provide details:
(if needed send details
separately to
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| # Jobs Run @ Time
Annual Volume $
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| Largest Job $
Average Job $
Smallest Job $
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| Do you have a Service Department?
Yes
No |
| Do you have 24 hour coverage?
Yes
No |
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| 5 References (Owners, Architects, and
at least 2 General Contractors for work completed within the last 2 years): |
| Contact:
Company:
|
| Address:
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| Phone:
Fax:
Your Contract $
|
|
| Contact:
Company:
|
| Address:
|
| Phone:
Fax:
Your Contract $
|
|
| Contact:
Company:
|
| Address:
|
| Phone:
Fax:
Your Contract $
|
|
| Contact:
Company:
|
| Address:
|
| Phone:
Fax:
Your Contract $
|
|
| Contact:
Company:
|
| Address:
|
| Phone:
Fax:
Your Contract $
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|
| 3 Vendor References: |
| Contact:
Company:
|
| Address:
|
| Phone:
Fax:
Ave. Mo. Purchase $
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|
| Contact:
Company:
|
| Address:
|
| Phone:
Fax:
Ave. Mo. Purchase $
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| Contact:
Company:
|
| Address:
|
| Phone:
Fax:
Ave. Mo. Purchase $
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NOTE: NORTH BRANCH
REQUIRES AN INSURANCE CERTIFICATE ON FILE INDICATING BOTH GENERAL LIABILITY
AND WORKERS' COMPENSATION INSURANCE AND EXPIRATION DATES.
You can attach any relevant digitial files here:
File #1
File #2
OR MAIL TO: North Branch Construction, Inc., 76 Old Turnpike Road, Concord, NH
03301
NO SUBCONTRACTOR WILL BE PRE-QUALIFIED WITHOUT
AN INSURANCE CERTIFICATE ON FILE |
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