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Vendor Qualification Form

Please fill out the form below. A * denotes required fields.

 Project Information
Project Name*
Project Location (City and State)*
 Vendor Information
Firm Name*
Firm Address*
Street* City* State Zip
Firm Contact Info*
Name* Phone* (numbers only) Fax* (numbers only) Email*
State if Incorporation*
Primary Trade Work*
Work value average for
past five (5) years*		 $
Last three (3) years
annual work value*
$ Year
$   Year
$ Year
Largest single project
work value*
$   Year

Project Name * Owner* Architect* Gen Contractor*
List three (3) Supplier references
for completed work in the last
two (2) years*
Firm* Products Supplied* Contact Person* Telephone*
 
 Financial Criteria
Bank Reference*
Name* Address* Years at this bank *
Total Line of Credit amount* Available?* `
 
Contact * Phone * Fax *
Payroll Taxes and Fringe Benefits
paid to date?
List State and Unemployment
Insurance Number
List State and Sales
and Use Tax Number
Attach most recent independent
audited financial statement 		 
 Insurance
Carrier of General Liability/
Workers Compensation/
Employer Liability Insurance
Contact
Name*

Phone*

 Fax *
 Bonding
Name of Bonding Company
Address
Street* City* State Zip
Contact
Name*

Phone*

 Fax *
 Safety
Workers Compensation experience
modifier for last three years
Year* EMR* Comments*
 
 Work Experience/Technical Ability
Three most significant projects
completed in last three years
Project/Address* Architect* Owner Contact* Amount* Yr Completed*
Owner references for
three largest projects
Reference* Contact Person* Phone Number*
Who will be your supervision
on the project (attach resume)
All signatory union affiliations
or typical trades used if not union
Percent of work to be performed by
your own forces (not subcontracted)		 %
Has your firm failed to
complete a contract?
Has your firm been involved in
bankruptcy or reorganization?
Has your firm been involved in
claims litigation or arbitration?
 Confirmation (To be signed by an officer of the company or an individual authorized by an officer of the company.)
Digital Signature*

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Name*
Title*
Date*