Subcontractor Qualification Form

0206500_CP_11_06_en_A3.2

Please complete the following to the best of your ability to submit and be pre-approved to perform work for Centennial or its JV Partners. To review Centennial's standard Terms and Conditions and/or state-specific supplemental Terms and Conditions: http://www.cce-inc.com/subcontracts/. Prequalification and/or evaluation of your firm cannot be completed without this information. Visit http://www.cce-inc.com to learn more about Centennial.

1. Company Information

Company Name*

Input company name as listed on current W-9 form.

Zip (9 Digits)*

To find your 9 digit zip code (the Zip +4) go to: http://zip4.usps.com/zip4/welcome.jsp

Contact Person's Title

Contact Person's Email*

Bid Requests

Click box if bid request should be sent to someone different than the contact listed above.

Contractor's License Number

Input contractor license number(s) for the state(s) the company is licensed in.

Federal Tax ID Number*

This number must match what is listed on the current W-9 form.

Primary Trade*

Select from the drop down menu.

Select or enter value

If Primary Trade is "Other", type in description here:

Secondary Trade

Select all that apply from the drop down menu.

Select or enter value

If Secondary Trade is "Other", type in description here:

2. Organization Information

SIC/NAICS Code(s)

You can find your NAICS (North American Industry Classification System) code here: http://www.census.gov/eos/www/naics/

DUNS Number

If your firm does not have a DUNS Number, you may request one from Dun & Bradstreet, Inc. at http://www.dnb.com/get-a-duns-number.html

WA State UBI Number*

If registered to do business in Washington State, provide the Dept. of Labor Industries UBI number. If you are not registered, go to https://secure.lni.wa.gov to complete the process.

Number of years in Business

Union(s) Affiliation - Name and Local Number

Apprentice Program Participant

Apprentice Program Name

3. Business Status

Please attach Certificate, as applicable, where indicated at the end of this form.

Business Status*

Select all that apply.

Select

If Business Status is "Other", type in status here:

SBA Certification*

Please attach SBA Certificate, as applicable, where indicated below.

Select

W/M/SBE/HUB Certifying Agency*

Name of Certifying Agency for W/M/SBE/HUB Certification. Attach certificate(s), as applicable, where indicated below.

HUB Certification Number

File Upload

Please attach your HUB, SBA or W/M/SBE Business Certificate (If Applicable) or any additional information about your company that you would like to share (e.g. capabilities summary, brochure, etc.).

Drag and drop files here or

4. Bonding Information

Centennial may require a subcontractor to bond depending on the project requirements. A project with hazardous activities must be bonded.

Can company provide a bond?*

Yes

Project Bonding Limit $*

Aggregate Bond Limit $*

5. HSEQ (Health, Safety, Environment, and Quality)

A Safety orientation must be scheduled with a Project Safety Manager prior to starting work on our project sites. This includes submitting a written Company Safety Program and Accident Prevention Plan (APP).

Safety Orientation*

Does your company have a Safety Program/Accident Prevention Plan (APP) in place?

Has your company been cited by OSHA/State for a safety violation in the last five (5) years?*

Yes

Experience Modification Rate (EMR)

Please list your firm's Experience Modification Rate for the most recent three years.

Modification Rate 2020

Modification Rate 2019

Modification Rate 2018

Recordable Incident Rate

Your firm's injury and illness rate (example: number of recordable incidents/illness multiplied by 200,000, divided by number of work hours on an annual basis = 3 x 200,000 / 500,000 = 1.2 [for every 100 employees, 1.2 are injured or ill].

Identify contract and building types your firm has worked on

Select

Project References

List at least three (3) completed projects:

Scope of Work performed

Year work was completed

Scope of Work performed

7. Credit References

List at least three (3) credit references.

Supplier/Vendor Name

Send me a copy of my responses

1. Company Information

2. Organization Information

3. Business Status

4. Bonding Information

5. HSEQ (Health, Safety, Environment, and Quality)

Experience Modification Rate (EMR)

6. Experience

Project References

Project Reference 1

Project Reference 2

Project Reference 3

7. Credit References