Contractor Prequalification Statement

Full Company Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Fax Number
Website
Person to Contact*
First Last
Email*
Enter Email Confirm Email
Phone*

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Organization Information
Organization Type*
- Corporation—Public
- Corporation—Private
- Proprietorship
- Partnership
- Other (please define below)
Other business type—please define
Incorporation (if applicable)
State Year
% of minority ownership in the firm*
Please enter a number from 0 to 100.
Is your firm an MBE, WBE, or a Sheltered Workshop?*
- Yes
- No
Certifications
Please identify the certifications you hold from other organizations or agencies (e.g., New York State, Upstate New York Minority Purchasing Council). Please upload documentation about all certifications below.
Certification documentation
Are you a subsidiary or another organization or corporation? If yes, specificy which.*
What services does your company provide?*
How many years have you been in this business?*

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Financial Information
List your annual sales volume for each of the last three years:*
Year Sales Volume
Dunn & Bradstreet Number
Bidding Limits*
Maximum Minimum
Bonding:*
Current Capacity Bonding Co. Name Bonding Co. phone Bonding Co. contact name
Insurance Requirements. Please attach certificate of insurance.*
Drop files here or
Largest contract completed to date ($ value):*
Year when your largest contract was completed:*
Please enter a number from 1990 to 2020.
Are there any judgments, claims, or suits pending or outstanding against you? If yes, please explain below.*
- Yes
- No
Are you now, or have you ever been involved in bankruptcy or reoganization proceedings? If yes, please explain below.*
- Yes
- No
If you answered yes to either of the previous two questions, please explain below.
What are the five largest projects and the dollar value of each project that you have worked on in the last 24 months?*

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Capabilities
Your company operates as a:
- Union shop
- Non-Union shop
- Both
Employee numbers*
Total Labor Force # Seasonal Employees # Year-Round Employees #
Do you comply with the provisions of Executive Orders 11246 (Equal Employment Opportunity), 11625 (Minority Business Enterprises), 12138 (Woman Owned Business), Vietnam Era Veterans' Readjustment Assistance Act (41 CFR 60-250), and the Rehabilitation Act (41 CFR 60-741)?*
- Yes
- No
What are the geographical limits of where you will perform work?*
What are the maximum and minimum dollar values of jobs you are interested in?*
Maximum $ Minimum $

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Safety History
OSHA information*
YEAR # Fatalities # Lost Workday Incidents # Restricted Workday Incidents # Other Reordable Incidents # Employee Hours Worked

Last three years from OSHA 300 form. Please upload copies below.
Company is exempt from OSHA recordkeeping*
- Yes
- No
(Fewer than 10 employees, SIC partial exempt, etc.)
Upload OSHA 300 form for past three years.*
Drop files here or
Please describe any OSHA citations obtained with the last five years. Include location, type of citation, hazard, penalty, and corrective action taken.*
Please describe any DOT citations/violations obtained with the last three years.*
Person responsible for on-site safety*
Contact Name: Phone:
DOT safety rating (last full year)*
- Satisfactory
- Unsatisfactory (as listed on fmcsa.dot.gov)

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Workers Compensation Insurance
Workers Compensation Insurance Company Name:*
Workers Compansation Risk Management Company (if any):
Experience Modification Rate (EMR) for current and past two years*
Current Year Rate Year/Rate Year/Rate
Safety Training
Do all on-site employees have a minimum 10-Hr OSHA Construction Industry Certification?*
- Yes
- No
Do all on-site supervisors have a minimum 30-Hr OSHA Construction Industry Certification?*
- Yes
- No
Do you have a written safety and health program? If yes, please upload below.*
- Yes
- No
Please upload written safety and health program.
Do you agree to follow C&S's safety and health guidelines/program as well as the client's health and safety program(s)?*
- Yes
- No
Do you provide site-specific safety training? Yes or No? If yes, please describe it.*
Do you perform on-site safety audits?*
- Yes
- No
Who performs on-site safety audits?
Do you have a "Competent Person" for the following? (check box for each)*
- Trenching/Excavating
- Scaffold Erection
- Confined Space
- Not Applicable
Do you have the following staff? (check all that apply)*
- Qualified Riggers (in accordance with 29CFR1926.1400)
- Qualified Signalmen (in accordance with 29CFR1926.1428)
- Not Applicable

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Organization Information

Current Capacity	Bonding Co. Name	Bonding Co. phone	Bonding Co. contact name

Total Labor Force #	Seasonal Employees #	Year-Round Employees #

YEAR	# Fatalities	# Lost Workday Incidents	# Restricted Workday Incidents	# Other Reordable Incidents	# Employee Hours Worked

State	Year

Year	Sales Volume

Maximum $	Minimum $

Current Year Rate	Year/Rate	Year/Rate