Sub-Contractor Registration

Company Name*

Area of Expertise*

Email*

Phone*

Address*

Tax ID / SS Number*

Contact Person*

Type of Company*

Date company formed*

Total number of employees*

States in which company is legally qualified to do business (Include type and license numbers)*

Names & Titles of Key Personnel in Company*

Has the company operated under any other name in the past five years?*

If yes, give name(s)?*

Does the company have offices, plants or warehouses at other locations?*

If yes, give location(s)?*

Is the company a Minority Business Enterprise (MBE), Women Business Enterprise (WBE), Small Business Enterprise (SBE) or any other type of certified business enterprise?*

If yes, what type?*

Does the company have a line of credit from any lending institution?*

If yes, please provide details:*

Lender's name, Address, Officer's name, Phone:*

Do you have the ability to bond projects?*

If yes, date of last bonded project:*

Single project limit*

Aggregate Limit*

Bonding Company Name, Address:*

In the past 5 years, has your company or any of its key personnel been investigated for or found to have committed a serious OSHA violation?*

If yes, provide details:*

What is your current Workman's Compensation EMR rate? Please attach a copy of current EMR at end of form*

Do you have written employee safety policy & program?*

Are there any open or aggregate liability claims that would impair your ability to insure a project?*

Do you have written employee safety policy & program?*

If yes, give date:*

Do you have written employee safety policy & program?*

If yes, give details*

Do you have written employee safety policy & program?*

If yes, give dates and details*

Do you have written employee safety policy & program?*

If yes, give details*

Current projects Include name of project, scope of work, contract amount and completion date*

Trade References Include name of project, scope of work, contract amount and completion date*

Client References List 3 clients, include names and phone numbers*