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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