Prequalification Form will NOT be accepted unless it is completed in its entirety.	Date Completed:

BUSINESS INFORMATION

Company Name:

Address:

If Corporate Office check here: Yes No

Primary Contact:

Phone:	Fax:

E-Mail:	Website:

Branch Offices:

Design/Build Experience: Yes No	If Yes, engineering staff is: Internal External

Years in Business Under Present Name: Years	Status: Union Non-Union

Employer Identification No.:

State Contractors License Number (where applicable):

Average Contract Size over the last five (5) years: $

Average annual revenue over the last five (5) years: $

Company Type:	Corporation Partnership LLC Individual DBA	Joint Venture Sole Proprietor

WORK PERFORMED

List the categories or CSI sections that your organization normally performs:

Check the categories your company has experience in:

Healthcare Education K-12 Higher Education Apartments Condos

Single Family Homes Industrial Retail Other Commercial

BUSINESS CLASSIFICATION

Does your business meet a special classification? Yes No

If yes, please complete the remainder of this section.

Minority Owned	Woman Owned	Small Business

Disadvantaged Business	HubZone	Veteran Owned

Other 1 _______________	Other 2 _______________	Other 3 _______________

Minority Certification Status:	N/A	Self Public Private

(Copy Required)

City:	NMSDC Affiliates:

State:	(National Minority Supplier Dev. Council)

Country:

INSURANCE

Does your company meet Collage Construction’s minimum standard insurance requirements? Yes No

If No, please attach a copy of your current insurance certification form.

BONDING

Is your company bondable? Yes No	(If N/A or not bondable, please attach explanation)

Bonding capacity in aggregate: $	Bonding capacity per project $

(Current $$ Value required, DO NOT state unlimited)

Bonding Rate per $1,000:

Bonding Company (Surety, not Agent):

(List complete Surety Name as it appears on the Dept. of Treasury’s Listing of Approved Sureties -Department Circular 570)

Bonding Company A.M. Best Rating:

Bond Agency Contact Name:	Phone:

PAST PERFORMANCE

Has your organization ever failed to complete any awarded work in the last seven (7) years? Yes No	(If Yes, attach explanation)

Are there any judgments, claims, arbitration proceedings and/or suits pending against your organization or its officers in the last seven (7) years? Yes No	(If Yes, attach explanation)

Has your organization filed any lawsuits or requested arbitration with regard to construction contracts within the last seven (7) years? Yes No	(If Yes, attach explanation)

SAFETY

How many OSHA violations has this business incurred over the past three years?

What is this business’ Workers’ Comp EMR history for the past 3 years & the current year?

Current Year ; 1 Year Ago ; 2 Years Ago ; 3 Years Ago

What is this business’ OSHA recordable incident rate for the past 3 years & the current year?

(Number of recordables x 200,000 / man-hours worked)

1 Year Ago ; 2 Years Ago ; 3 Years Ago

How many fatalities has this business incurred over the past three years?

Does this business have a written safety policy? Yes No	(A copy will be required if selected for project)

Does your company comply with the Drug Free Work Act? Yes No

REFERENCES

List Contact information for three (3) owners, general contractors, or construction managers for whom the company has worked in the past 5 years below:

Company	Contact	Phone	Email or Fax

List Contact information for three (3) suppliers from whom the company has purchased materials or subcontractors which the company has hired in the past 5 years below:

Company	Contact	Phone	Email or Fax

The undersigned certifies that the information provided herein is true and sufficiently complete so as not to be misleading.

Completed By (Print):

Signature:

Title:

Date Completed:

SUBCONTRACTOR

PREQUALIFICATION

FORM

THE COLLAGE COMPANIES	 Our mission is to build projects that strengthen the foundation and fabric of our community.

CGC020818	 HQ - 585 Technology Park  Lake Mary, FL 32746  407.829.2257  Fax 407.829.2258

PAGE 3	 The Most INFORMED Construction Services Company  Online: www.collage-usa.com

PROJECT INFORMATION SHEET

Valued Gateway Client

2009-04-16

COLLAGE