Prequalification Statement
Submitted To:Contact’s NamesSubmitted By:Contact’s NameDate:DateCompany & Location Information:Firm:Company Legal NameAddress:Office AddressCity:CityState:StateZip:ZipPhone:PhoneMain Preconstruction Contact Person:Name:NameTitle:TitleOffice Phone:Office PhoneExtension:Office Phone ExtensionCell:CellEmail:EmailReferences: Please list four different general contractors for whom you have performed similar scopes of work regarding similar facilities.1.Project2.Project(Project)(Project)General ContractorGeneral Contractor(General Contractor)(General Contractor)GC’s Project Manager Name and Phone NumberGC’s Project Manager Name & Phone Number(GC’s Project Manager Name & Phone Number)(GC’s Project Manager Name & Phone Number)Approximate Contract ValueApproximate Contract Value(Approximate Contract Value)(Approximate Contract Value)3.Project4.Project(Project)(Project)General ContractorGeneral Contractor(General Contractor)(General Contractor)GC’s Project Manager Name & Phone NumberGC’s Project Manager Name & Phone Number(GC’s Project Manager Name & Phone Number)(GC’s Project Manager Name & Phone Number)Approximate Contract ValueApproximate Contract Value(Approximate Contract Value)(Approximate Contract Value)Company Information:Self-Performed Scopes of Work:Scopes of WorkSubcontracted Scopes of Work:Scopes of WorkType of Firm:Corporation?Partnership?Individual?OtherOtherParent Company:Same?Name:NameYears in business as Contractor under present firm name:YearsLicense Number:License Number.States in which your company will do business:List out all States.Is your organization union?Yes?No?If so list the affiliation(s) and local(s):Affiliation(s) and Local(s)Provide information which would indicate the size and capacity of your organization, including the number or permanent employees engaged in (do not count the same employee twice):Estimating:NumberField Supervision:NumberTradespeople:NumberClerical / Accounting:NumberManagement:NumberIs your organization a registered DBE contractor?Yes?No?If so list certification type / number / body:Click here to enter text.What is your organization’s Experience Modification Rate (EMR)?Modification RateHas your firm ever failed to complete a contract or been assessed schedule related damages?Yes?No?Has your firm had any subcontractors fail to complete a contract in the last five yearsYes?No?Are there any judgments, claims, liens, or suits pending or outstanding against your firm?Yes?No?Has your firm been a party to any lawsuits, arbitration, or mediation with regard to construction projects in the last five years?Yes?No?*(If answer to any of the above questions is yes, please attach explanation to this form)Annual Billing:This year’s projected billing:$BillingThree Years Ago - Billing:$BillingLast Years - Billing:$BillingFour Years Ago - Billing:$BillingTwo Years Ago - Billing:$BillingFive Years Ago - Billing:$BillingFive Largest Projects Completed in the Last Five Years:ProjectGeneral Contractor, Contact and Phone NumberContract AmountProjectGeneral Contractor, Contact and Phone Number$Contract AmountProjectGeneral Contractor, Contact and Phone Number$Contract AmountProjectGeneral Contractor, Contact and Phone Number$Contract AmountProjectGeneral Contractor, Contact and Phone Number$Contract AmountProjectGeneral Contractor, Contact and Phone Number$Contract AmountMajor Projects Under Contract:Project% of Contract CompleteCompletion DateContractorTotal Contract ValueProject% CompleteDateContractor$Click here to enter text.Project% CompleteDateContractor$Click here to enter text.Project% CompleteDateContractor$Click here to enter text.Project% CompleteDateContractor$Click here to enter text.Project% CompleteDateContractor$Click here to enter text.Total value of projects under contract: (including those not listed above)$Click here to enter text.Percent of negotiated / bid contracts%% Negotiated / % BidCurrent Pursuits: Current projects you are current a candidate for. (Indicate size and schedule)ProjectStart DateContractorTotal Contract ValueProjectDateContractor$Click here to enter text.ProjectDateContractor$Click here to enter text.ProjectDateContractor$Click here to enter text.ProjectDateContractor$Click here to enter text.ProjectDateContractor$Click here to enter text.Bonding InformationWhat is your bond rate for this project (as a percentage)%RateAggregate Limit:$Aggregate LimitSingle Project Limit:$Single Project LimitPlease list the names of your bonding agent and surety:Bonding AgentSurety(Bonding Agent)(Surety)Street AddressStreet Address(Street Address)(Street Address)City, State, ZipCity, State, Zip(City, State, Zip)(City, State, Zip)The answers to the foregoing questions and all statements herein contained are true and correct.Reviewer’s NameReviewer’s Position(Reviewer’s Name)(Reviewer’s Position)* Holder Construction reserves the right to request Audited Financials which is defined as a Balance Sheet, and Income Statement, an Auditor’s Report and Footnotes. ................
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