Legal Company Name:
Date:
Physical Address:
Mailing Address:
Phone #
Fax #
Email Address:
Web Address:
Federal Tax ID#
Years in Business Under Present Name:
Geographic Area of Business Operations:
Contracting Scope:
AIA Divisions for which your company is qualified/licensed to perform:
Check type of business:
Corporation: Yes No Partnership: Yes No Individual: Yes No Joint Venture: Yes No Other: Yes No
Principals of Firm / Title:
Total Number of Permanent Employees:
Preferred Minimum and Maximum Size of Project your company seeks in Dollars: $ Minimum $ Maximum

Work History
List at least Four (4) of the most Significant Projects your company worked on in the past 12 months:

Project:
General Contractor:
Address:
City:
State:
Zip:
Contact:
Phone:
Fax:
Contract Amt:$

Project:
General Contractor:
Address:
City:
State:
Zip:
Contact:
Phone:
Fax:
Contract Amt:$

Project:
General Contractor:
Address:
City:
State:
Zip:
Contact:
Phone:
Fax:
Contract Amt:$

Project:
General Contractor:
Address:
City:
State:
Zip:
Contact:
Phone:
Fax:
Contract Amt:$

Licenses
List Jurisdictions and Trade Categories in which your Organization is Legally Qualified to do Business, and indicate Registration or License Numbers.

License #		Jurisdiction:		Category:
License #		Jurisdiction:		Category:
License #		Jurisdiction:		Category:
License #		Jurisdiction:		Category:

Safety

Does your Firm have a Written Safety Program:		Yes No
What is your Work Comp Experience Mod Rate:
In the Previous (3) Three years, has your Firm been cited for a serious violation (as defined by OSHA)?		Yes No
If yes, list violations:

Insurance and Bonding

Value of Work Presently Bonded $
Total Bonding Capacity $
Bonding Surety:
Bonding Agent:
Contact:
Phone:
Insurance Agent:
Contact:
Phone:

Financial

Bank References

Bank:
Address:
City:
State:
Zip:
Contact:
Phone:
Fax:
Account #:

Has your Firm failed to complete a contract? yes no
Has your Firm been involved in bankruptcy or reorganization? yes no
Does your Firm have any pending judgment claims or suits? yes no


Contact Information

General Contact Person / Title:
Phone #
Cell Phone #
Fax #
Email Address:

Estimating Contact Person / Title
Phone #
Cell Phone #
Fax #
Email Address:

Office Contact Person / Title:
Phone #
Cell Phone #
Fax #
Email Address:

Additional Contact Person / Title:
Phone #
Cell Phone #
Fax #
Email Address: