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Avalon Park Wesley Chapel
Marriott Palmetto at the Bradenton Convention Center
Springhill Suites Tampa
701 E. Whiting Street
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SUBCONTRACTOR PREQUALIFICATION FORM
Subcontractor Pre-Qualification Form
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General Information
Legal Company Name
Federal Tax ID Number
Current Licenses
Mailing Address
Street Address
Address Line 2
Business Phone
Business Fax
Contact Name
Contact Email
Website
Company Established
Month
Day
Year
Form of Business (check all that apply)
Sole Proprietorship
Partnership
Corporation
SBE
MBE
WBE
Other
Other
Number of Employees
Are Any LEED Accredited?
Safety Information
What is Your EMR for This Year?
What was Your EMR for Last Year?
What was Your EMR Prior to Last Year?
Are your employees 10-hr OSHA Certified?
Yes
No
How many and what positions are they trained?
Are your employees 30-hr OSHA Certified?
Yes
No
How many and what positions are they trained?
Work Experience
Experience – Scope of Work (Check all that apply)
Div. 01 – General Requirements
Div. 02 – Site Development
Div. 03 – Concrete
Div. 04 – Masonry
Div. 05 – Metals
Div. 06 – Carpentry
Div. 07 – Roofing/Siding
Div. 08 – Doors/Windows
Div. 09 – Finishes
Div. 10 – Fixtures
Div. 11 – Equipment
Div. 12 – Furnishings
Div. 13 – Special Construction
Div. 14 – Elevators/Lifts
Div. 21, 22, 23 – Mechanical
Div. 26, 27, 28 – Electrical
Other (specify below)
Other
Experience – Overal
Of the scope of work, please complete the following information for further evaluation.
Division/Trade
Business Name Under Which Trade is/was Performed
Years Performing Trade Under this Name
Division/Trade
Business Name Under Which Trade is/was Performed
Years Performing Trade Under this Name
Division/Trade
Business Name Under Which Trade is/was Performed
Years Performing Trade Under this Name
Division/Trade
Business Name Under Which Trade is/was Performed
Years Performing Trade Under this Name
Do You Need to Add More Experience?
Yes
No
Experience – Overall (Continued)
Completed Projects
Project Name
Dollar Amount
Contract Completion Date
MM slash DD slash YYYY
Contractor
Contact Name
Contact Phone
SBE, MBE, or WBE?
Project Name
Dollar Amount
Contract Completion Date
MM slash DD slash YYYY
Contractor
Contact Name
Contact Phone
SBE, MBE, or WBE?
Project Name
Dollar Amount
Contract Completion Date
MM slash DD slash YYYY
Contractor
Contact Name
Contact Phone
SBE, MBE, or WBE?
Project Name
Dollar Amount
Contract Completion Date
MM slash DD slash YYYY
Contractor
Contact Name
Contact Phone
SBE, MBE, or WBE?
Experience – Facilities & Equipment
List your company's facilities and major equipment, leased or owned.
Do you need more space?
Yes
No
Continue to list your company's facilities and major equipment, leased or owned.
Regulatory / Contractual
If relevant to your company, include an explanation of all occurrences from the list below that have taken place in the last 5 years, or indicate “no” if irrelevant. Provide sufficient and appropriate detail information such as “project name, owner, contact person and contact phone number, and amount of contract, etc.”
Any judgments, claims or suits pending or outstanding against your company?
Yes
No
If yes, include a brief explanation of each.
Company
Any judgments, claims or suits pending or outstanding against a client or general contractor?
Yes
No
If yes, include a brief explanation of each.
Client or GC
Any citations by OSHA for violations in the last five (5) years?
Yes
No
If yes, please include list of violations, status, and fine amount.
OSHA
State or Federal Prevailing Wage violations or judgments?
Yes
No
If yes, please include list of violations and status.
State Wages
Company Policies and Statistics
Does your company have workers compensation through the State of Florida?
Yes
No
If yes, please include your current certificate. If no, please explain. (You may use the “Additional Blank Pages” at the end of this form)
Workers Compensation Certificate
Drop files here or
Select files
Max. file size: 25 MB, Max. files: 5.
Workers Comp Explanation
Automobile Insurance
Insurance Company
Limits
Date of Renewal
MM slash DD slash YYYY
Employers Liability Insurance
Insurance Company
Limits
Date of Renewal
MM slash DD slash YYYY
General Liability Insurance
Insurance Company
Limits
Date of Renewal
MM slash DD slash YYYY
Excess Insurance
Insurance Company
Limits
Date of Renewal
MM slash DD slash YYYY
Bonding
Bonding Company
Bonding Capacity
Please Include your current bonding certificate(s) of insurance
Drop files here or
Select files
Max. file size: 300 MB, Max. files: 25.
Company Policies and Statistics (continued)
Does your company have:
Training/orientation on sexual harassment in the workplace?
Yes
No
A written Disciplinary Policy?
Yes
No
A written Hazardous Communication Program?
Yes
No
Safety orientation for new hires?
Yes
No
Mandatory weekly safety meetings?
Yes
No
A designated Safety Officer for your company?
Yes
No
A Substance Abuse Policy?
Yes
No
Pre-hire Testing?
Yes
No
Post-hire/Random Testing?
Yes
No
Are you willing to require your employees to be subjected to site, project, or Owner specific drug and/or alcohol testing programs?
Yes
No
Company Associations
Has your company:
Been required to issue joint party checks to you and your suppliers or subcontractor?
Yes
No
If yes, include a brief explanation of each.
Joint Party Checks
Been assessed liquidated damages for late completion of a project within the last three (3) years?
Yes
No
If yes, include a brief explanation of each.
Liquid Damages
Been associated with or worked for LEMA under your current or another company name?
Yes
No
If yes, under which company name?
Which company name?
Previously worked on a LEMA project?
Yes
No
If yes, list up to five (5) most recent projects. Add additional pages if desired.
Project #1
Project #2
Project #3
Project #4
Project #5
Financials
Projected Annual Sales
Current Uncompleted Backlog
Are you willing to provide the following information, if required?
An annual financial statement prepared within the 12 months prior to the prequalification request by an independent licensed accounting firm; and the name, address, contact person and phone number of the bank normally used by the Bidder for its primary banking;
Yes
No
A financial report generated from Standard and Poor, Dun and Bradstreet or a similar company acceptable to LEMA documenting the financial condition of the Bidder; and the name, address, contact person and phone number of the bank normally used by the Bidder for its primary banking;
Yes
No
This information is not a public record under Ohio Revised Code Section 149.43; and shall remain confidential, except under proper order of a court.
Full Name of Company Principal
Signature
Date
MM slash DD slash YYYY
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Avalon Park Wesley Chapel
Marriott Palmetto at the Bradenton Convention Center
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701 E. Whiting Street
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