North Branch: Sub Contractor Pre-Qualifications

Contact Person *

Company Name *

Address *

City *

State *

Zip *

Phone Number *

Fax Number *

Email *

Federal ID# *

Division *

Scope of work *

Year Business Started *

Number of Employees *

Website *

MBE/WBE/DBE

Form of Ownership

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

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

Average Number of Jobs Running at a Time

What is your current Worker's Compensation Experience Modification Rating (EMR)? *

Do you have a Service Department?

Do you have 24-hour coverage?

Does your firm have a written safety plan?

Does your firm have a written Hazardous Communications Program? *

Have you ever failed to complete a project? *

Have you ever failed to complete a project on time? *

Have you had a contract terminated due to performance? *

Contract Termination Details

Has your firm been cited by OSHA for any Serious, Willful or Repeat Safety Violations in the last 5 years? *

OSHA Citation Details

Have you participated in any legal, arbitration or mediation proceedings in the last five years? *

Legal Proceedings Details

Has Company or any of its Owners Declared Bankruptcy in last 5 years? *

Is the Company Bondable? *

If Bondable, what is your single project limit $

Total limit $

Annual Volume $ *

Largest Job Value *

Average Job Value *

Smallest Job Value *

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

Ref. 1 Contact *

Ref. 1 Company *

Ref. 1 Phone *

Ref. 1 Email *

Ref. 1 Full Address *

Ref. 1 Contract $ *

Ref. 2 Contact *

Ref. 2 Company *

Ref. 2 Phone *

Ref. 2 Email *

Ref. 2 Full Address *

Ref. 2 Contract $ *

Ref. 3 Contact *

Ref. 3 Company *

Ref. 3 Phone *

Ref. 3 Email *

Ref. 3 Full Address *

Ref. 3 Contract $ *

Ref. 4 Contact

Ref. 4 Company

Ref. 4 Phone

Ref. 4 Email

Ref. 4 Full Address

Ref. 4 Contract $

Ref. 5 Contact

Ref. 5 Company

Ref. 5 Phone

Ref. 5 Email

Ref. 5 Full Address

Ref. 5 Contract $

3 Vendor References

Vendor. 1 Contact *

Vendor. 1 Company *

Vendor. 1 Phone *

Vendor. 1 Email *

Vendor. 1 Address *

Vendor. 1 Avg. Monthly_Purchase *

Vendor. 2 Contact *

Vendor. 2 Company *

Vendor. 2 Phone *

Vendor. 2 Email *

Vendor. 2 Address *

Vendor. 2 Avg. Monthly_Purchase *

Vendor. 3 Contact

Vendor. 3 Company

Vendor. 3 Phone

Vendor. 3 Email

Vendor. 3 Address

Vendor. 3 Avg. Monthly_Purchase

NOTE: NORTH BRANCH REQUIRES AN INSURANCE CERTIFICATE ON FILE INDICATING BOTH GENERAL LIABILITY AND WORKERS' COMPENSATION INSURANCE AND EXPIRATION DATES.

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