Subcontractors – Jorgenson Construction

Subcontractor Identity

Company Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Fax

Contact Name

Email Address

Federal Tax ID#

NAICS Code

DUNS #

States Registered to do Business

W-9

Include a copy of a completed W‐9 form if company has not worked with Jorgenson Construction in past 12 months. Accepted file formats include jpg, gif, png and pdf.

Type of Company

List Company Officers

Chairman

President(s)

Vice President(s)

Secretary

Treasurer

Date Company formed

Number of Employees: Salaried

Number of Employees: Hourly

Contract Value Summary
Current Year - Backlog (at year end for prior years)
Current Year - Value of Contracts in Progress (at year end for prior years)
Current Year - Total Revenue
Prior Year #1 - Backlog (at year end for prior years)
Prior Year #1 - Value of Contracts in Progress (at year end for prior years)
Prior Year #1 - Total Revenue
Prior Year #3 - Backlog (at year end for prior years)
Prior Year #3 - Value of Contracts in Progress (at year end for prior years)
Prior Year #3 - Total Revenue
Prior Year #4 - Backlog (at year end for prior years)
Prior Year #4 - Value of Contracts in Progress (at year end for prior years)
Prior Year #4 - Total Revenue
Average contract value last three (3) years
Largest single contract completed in last three (3) years
Size of projects preferred
Project location preferred
Does company have offices, plants or warehouses at other locations?
Yes
No
If yes, list addresses
List trade(s) of work performed by company
Union Affiliation
Is the company directly or indirectly signatory to any union labor agreements?
Yes
No
If yes, list union affiliations
If yes, does company have a bond in place securing your payment of wages and fund contributions as required by your labor union agreement?
Yes
No
Bonding Capability
Is the company able to bond projects?
Yes
No
Bonding Rate
Single project limit
Aggregate Limit
Value of current bonded contracts
Bonding Company/Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Agent Name/Phone#
A.M. Best Financial Strength Rating of Surety
File
If company is able to bond, provide letter from company’s surety affirming surety’s commitment to the single project and aggregate limits inserted above.
Banking
Bank Name
Number of Years with this Bank
Bank Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Name
Contact Phone Number
Does the company have a line of credit from any lending institution?
Yes
No
If yes, what is amount of line of credit?
Amount of available line of credit as of this date
Contact information of lending institution if different from bank listed above
Certification
Certifications
Check applicable certification(s): Attach copies of certifications for each qualifying SBA Classification.
Large Business (no special classification)
Small Business enterprise (SBE)
Minority Business Enterprise (MBE)
Veteran Owned Small Business (VOSB)
HUBZone Small Business
Service Disable Veteran Owned Small Business (SDVOSB)
Small Disadvantages Business (SDB)
Women Owned Small Business (WOSB)/(WBE)
8(a) Certified Small Disadvantaged Business
Alaskan Native Corporation (ANC)
Native American/Indian Tribe
Other
Other
Completed Projects
List four (4) representative projects completed in the last five (5) years.
Please list Project Name, Contracting Company, Contact Name/Phone, Contract Amount and Completion Date for EACH project.
Current Projects
List four (4) representative projects currently under construction.
Please list Project Name, Contracting Company, Contact Name/Phone, Contract Amount and Completion Date for EACH project.
Trade References
List three (3) of your subcontractors or suppliers.
Please list Company Name, Address and Contact Name/Phone for EACH project.
Client References
List three (3) clients
Please list Company Name, Address and Contact Name/Phone for EACH project.
If necessary, include attachments listing completed project, current projects, trade and client references.

Drop files here or

Company's Commitment to Mitigating the Environmental Impacts of Construction
Does the company have an environmental mission statement and/or policy?
Yes
No
Does the company have a waste reduction and recycling program?
Yes
No
Does the company educate employees and vendors about this program?
Yes
No
Does the company participate in the salvage and/or reuse of wasted materials?
Yes
No
Does the company utilize recycled content construction materials?
Yes
No
Safety Information
OSHA RECORDS
Has your firm had any OSHA citations, fines or jobsite fatalities within the most recent three(3) years?
Yes
No
If yes, please attach a detailed description of the incident.
(include – location, date, type or inspection, standard(s) cited, violation type (other, serious, repeat, willful), current status and steps taken to prevent a recurrence.)
Workers’ Compensation
Please list your firm’s workers’ compensation experience modification rate (EMR) for the last three (3) years and attach written documentation from your insurance broker confirming these rates.
Year : Rate : Year : Rate : Year : Rate :
Documentation from your insurance broker confirming the rates from above.

Drop files here or

Employee hours worked the last three (3) years
Other Information
In the past five (5) years, has the company, operated under any other name?
Yes
No
In the past five (5) years, has the company, had any liens filed against it by any of its subcontractors, suppliers or taxing authority?
Yes
No
In the past five (5) years, has the company, had any judgments, claims, arbitration proceedings or suits against it or its officers?
Yes
No
In the past five (5) years, has the company, filed any lawsuits or request arbitration with regard to a construction contract?
Yes
No
In the past five (5) years, has the company, ever failed to complete a contract, been defaulted, or had a contract terminated?
Yes
No
In the past five (5) years, has the company, had liquidated damages assessed against it upon completion of a project?
Yes
No
In the past five (5) years, has the company, or any of its key people been a party to a bankruptcy or reorganization proceeding?
Yes
No
In the past five (5) years, has the company, or any of its key people been investigated for or found to have committed a violation of any labor laws?
Yes
No
In the past five (5) years, has the company, or any of its key people been investigated for or found to have committed a violation of state, federal or local laws?
Yes
No
In the past five (5) years, has the company, had active or inactive exclusions associated with it or any key personnel as determined by the Federal Government Systems for Award Management (S.A.M.)?
Yes
No
Give details for any yes answer.
Additional Information
Please attach any additional information to help us determine your company’s qualifications and expertise.

Drop files here or

I hereby certify that the information herein is true and sufficiently complete so as not to be misleading.
Signature
Printed Name
Title
Date

Contractor’s License No.
Please Include
Audited financial statements, Key personal resumes, Insurance Certificate, Copy of all contractor’s licenses, W‐9 form if new to Jorgenson, Surety Letter
Submission of Requested Financial Information is a Requisite for becoming a Pre-Qualified Subcontractor

Pre‐Qualification Application

Subcontractor Identity

List Company Officers

Union Affiliation

Bonding Capability

Banking

Certification

Completed Projects

Current Projects

Trade References

Client References

Company's Commitment to Mitigating the Environmental Impacts of Construction

Safety Information

OSHA RECORDS

Workers’ Compensation

Other Information

Additional Information

Submission of Requested Financial Information is a Requisite for becoming a Pre-Qualified Subcontractor