Prus Subcontractor Prequalification

GENERAL INFORMATION

Company Name*

Federal Tax ID*

Address*

Company Phone #*

Company Fax#

Contact Name*

Contact Phone #*

Contact Email*

List of Executive Officers' Names & Titles (I.e: President, CEO, Vice President, CFO)*

COMPANY HISTORY

Date Company Began Under Present Name*

Former Company Name*

Years performing under current name*

Company Type (i.e: Corporation, Limited Liability, Joint-Venture)*

Any Affirmative Action Violations in the past 5 years? If yes, attach details below.*

If yes, attach details below.

Yes

No

CERTIFICATIONS

Please list any MBE, WBE, EDGE, DBE, SBE, or Other Certifications below and attach certificate(s) at the bottom of this form.*

FINANCIAL INFORMATION

Bank Company Name*

Bank Phone #*

Bank Contact (If Applicable)

Balance Sheet from Previous Year

SURETY & INSURANCE INFORMATION

Surety Company Name*

Surety Agent Contact*

Surety Agent Phone*

Insurance Company Name*

Insurance Agent Contact*

Insurance Agent Phone*

Total Bonding Capacity*

Current Bonded Amount*

STATEMENT OF EXPERIENCE

Key Construction Personnel for Project (Name, Title, Phone#, Email, Experience)*

Past (5) completed projects relevant to this project.*

Please provide the following for each: project name, owner, start date, completion date, total amount of project. Attach files below if necessary.

Current (3) Projects*

Please provide the following for each: project name, owner, start date, completion date, total amount of project. Attach files below if necessary.

In the past three (3) years, has your company defaulted, been terminated for cause or failed to complete a construction contract awarded to it?*

Yes

No

In the past three (3) years, has any officer, partner, joint venture or proprietor of your company ever failed to complete a construction contract awarded to that person or entity in their name or on behalf of another organization?*

Yes

No

In the past five (5) years, has your company been charged liquidated damages because of your inability to meet the contractual schedule requirements?*

Yes

No

If you answered "Yes" to any of the last three (3) questions, please give a brief description why.

Describe all litigation arising from your company’s active projects or projects worked on within the last three years.*

Annual Construction Volume*

Merit-Shop?*

Please note this pre-qualification is for an OFCC/ODOT project which requires prevailing wage rates be administered to all employees on site.

Yes

No

Union Affiliations?*

Geographical Areas*

Trades*

REFERENCES

Please List (2) General Contractor/Construction Manager References*

Include Company Name, Address, Contact, Phone #

Please List (2) Material Supplier References*

Include Company Name, Address, Contact, Phone #

Please List (2) Business References*

Include Company Name, Address, Contact, Phone #

SAFETY PROGRAM

Safety Officer Name*

Safety Officer Phone #*

Safety Officer Email*

Do You Have a Written Safety Program?*

If "Yes", please attach your program below.

Yes

No

Do You Have a Drug & Alcohol Testing Policy?*

If "Yes", please attach your policy below.

Yes

No

List Workers Compensation Experience Modification Rate (EMR) for the Current Year*

Last Year EMR*

Two Years Ago EMR*

Three Years Ago EMR*

List Total Recordable Incident Rate (TRIR) for Last Year*

OTHER INFORMATION

Within the past three (3) years, has your company or any of the individuals identified as the Executive Officers and/or Key Personnel has/have been the subject of any criminal indictment or judgment of conviction for any business-related conduct constituting a crime under state or federal law?*

Yes

No

If "Yes", give a brief description why.

Has your company, or any of the individuals identified as the Executive Officers and/or Key Personnel has/have been the subject of any bankruptcy proceeding within the last three years?*

Yes

No

If "Yes", give a brief description why.

Within the past three (3) years, has your company or any of the Executive Officers and/or Key Personnel been the subject of any formal proceeding or consent order with a state or federal environmental agency involving a violation of state or federal environmental laws?*

Yes

No

If "Yes", give a brief description why.

Within the past three (3) years, has your company or any of the Executive Officers and/or Key Personnel been the subject of any federal or state suspension or disbarment?*

Yes

No

If "Yes", give a brief description why.

Attachments

Please attach: 1. Workers Comp. 2. Certificate of Insurance indicating current limits 3. EEO Certificate of Compliance 4. Proof of current licenses to perform associated work 5. Additional documents deemed necessary

File Attachments*

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