SUPPLEMENTAL INFORMATION TO THE AIA A305 …
Subcontractor Qualification Form – (Do not use this form for Construction Manager at Risk projects).
Date: ___________________
Please provide the following information so that we can identify your company and notify you of upcoming projects that match your qualifications. Information is required to determine eligibility. Incomplete information may result in your company being excluded from bid solicitation.
Company Name:
Physical Address:
Primary Contact:
Telephone:
E-mail Address:
Estimating Contact:
Telephone:
E-mail Address:
List scopes of work you self-perform:
Additional Business Information:
Please check any of the following that apply to your organization and attach documentation from any local, state, or federal agency that has certified you as such:
African American Owned
Asian American (incl. Pacific Islander and Middle-Eastern) Owned
DBE (Disadvantaged Business Enterprise)
Hispanic Owned
HUB (Historically Underutilized Business) Contractor
LDB (Local Developing Business)
Native American Owned
Service Disabled Veteran Owned
Woman Owned
Veteran Owned
None Apply
Other
Bonding and Construction Capacity Information:
|Is your company bonded? | YES NO |
|Bond Company Best Rating of “A” or Better? (Attach letter from surety): | YES NO |
|Present bonding capacity – Aggregate: |$ | |
|Bonding capacity – Per project limit: |$ | |
|Current bond amount available – Aggregate: |$ | |
|Value of work in place last year: |$ | |
|Value of largest contract completed: |$ | |
|List the minimum job value for which you prefer to perform work: |$ | |
|List the maximum job value for which you prefer to perform work: |$ | |
|Percent (%) of work performed by own forces: | | % |
|Total number of permanent staff presently employed by your firm: | | |
Environmental, Health and Safety Issues:
|Do you carry Worker’s Compensation? | YES NO |
|Provide Worker’s Compensation Insurance Experience Modification Rate (EMR) for the past 5 years. | |
|2018 | |
|2017 | |
|2016 | |
|2015 | |
|2014 | |
|Does your firm have a written safety and environment program? | YES NO |
|Does your firm have a written substance abuse program/policy? | YES NO |
|Does your firm have an instruction program for new hires and foremen? | YES NO |
|Has your firm had any OSHA fines within the last 3 years? | YES NO |
|Has your firm had any job-related fatalities within the last 3 years? | YES NO |
|(If you answered YES to either of the above 2 questions, submit on a separate sheet, the details | |
|describing the circumstances surrounding each incident). | |
Litigation/Claims History:
|Has your firm ever failed to complete any work awarded to it? | YES NO |
| | |
Additional Reference Information:
List three (3) contractor or owner references:
A. Company Name:
Contact Name:
Address:
Phone:
E-mail:
B. Company Name:
Contact Name:
Address:
Phone:
E-mail:
C. Company Name:
Contact Name:
Address:
Phone:
E-mail:
Please Submit your completed form to one or more of the following contacts according to the markets you work in.
Raleigh Division
Preconstruction Administrator
Clancy & Theys Construction Company
516 West Cabarrus Street, Raleigh, NC 27603
estimating@
Telephone: 919-834-3601
Fax: 919-834-2439
Wilmington Division
Zach Cromer – Manager of Preconstruction Services
Clancy & Theys Construction Company
516 West Cabarrus Street, Raleigh, NC 27603
2250 Shipyard Blvd., Suite 1
Wilmington, North Carolina 28403
zachcromer@
Telephone: 910-392-5220
Charlotte Division
John Homa – Estimator
Clancy & Theys Construction Company
7730 England Street
Charlotte, North Carolina 28273
johnhoma@
Telephone: 704.357.6602
Newport News Division
Haley Jackson – Preconstruction Assistant
Clancy & Theys Construction Company
11830 Fishing Point Drive, Suite 201
Newport News, Virginia 23606
haleyjackson@
Telephone: 757-873-6869
Orlando Division
Shelia Muniz – Estimating Coordinator
Clancy & Theys Construction Company
7308 Greenbriar Parkway
Orlando, FL 32819
sheilamuniz@
Telephone: 407-578-1449
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