Subcontractor Pre-qualification Form

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Company Information

13. Is your Firm Affiliated with any other company?

If yes, please list all applicable names below:

SMALL BUSINESS AND FEDERAL CONTRACTS SECTION

PLEASE UPLOAD ALL APPLICABLE MINORITY CERTIFICATIONS TO THIS FORM (FORM MUST HAVE THE “UPLOAD FILE FEATURE”)

1c. List up to four references

COMPANY EXPERIENCE:

1. Please specify the type and size of work that your company has been historically involved with:

SMALL (less than $550k)
MEDIUM (more than $550k)
LARGE (more than $2 Million)

2. List section /description of work your company performs by order of magnitude:
(Type N/A for no answer)

3. List Licenses Contractor holds and state of operation:

% of the work with our own forces.

7. List major construction projects your organization has in progress by order of magnitude.

FINANCIAL DATA
Please Note: Contractor must be able to bond amount of contract considered below.

4. Average (latest three years) yearly volume of work completed.

SAFETY RECORD AND PROGRAM
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2. Number of employee hours worked (Do not include any non-work time even if paid.)

3. Please, calculate incidence rate (I.R) for each year for each year record able and lost time accidents using the following formula:

N= Number of cases from OSHA Log N x 200,000
Employee Hours Worked (given year) = I.R. 
If the answer is yes, make program available for inspection upon request.
If the answer is yes, make program available for inspection upon request.
If the answer is yes, make program available for inspection upon request.
Please provide authorized full name