Subcontractor Prequalification Form

11/07/2012

Subcontractor Prequalification Form

Prospective subcontractors interested in working on our projects with a Flintco Subcontractor Bonding Program or Flintco Controlled Insurance Program are required to complete this Form. The contents of this Form will be considered confidential and used solely to determine your firm's qualifications and will not be disclosed to others. PLEASE COMPLETE THIS FORM ON A COMPUTER, IF YOU DID NOT RECEIVE AN ELECTRONIC COPY, GO TO WWW.FLINTCO.COM TO DOWNLOAD UNDER SUBCONTRACTORS – FORMS TAB.

I. GENERAL INFORMATION

A. Federal Tax ID:

B. Name of your business:

Address (City, ST, ZIP): Mailing (City, ST, ZIP):

C. Contact name and title:

D. Telephone number: Fax number: Email: Cell:

E. Trade description(s):

No Yes

F. Are you listed in Dun & Bradstreet?

If yes, what is your rating?

No Yes

G. Are you Native American Owned?

If yes, please provide name of recognized Tribe.

II. ORGANIZATION

A. Business type:

CORPORATION, PARTNERSHIP, Subchapter – S Corporation, LIMITED LIABILITY COMPANY, SOLE PROPRIETOR, OTHER (SPECIFY):

B. Years in Business: State of formation

C. Please provide the following information about all company officers, or principals:

Name / Title / Time in Position / % Ownership

D. Indicate if your business qualifies as one of the following: (check all that apply)

DBE MBE SBE WBE DVBE (Provide copy of certification)

E. List other names your firm has conducted operations under in the past 5 years:

F. Is your firm owned or controlled by a parent company or any other organization? No Yes

If yes, please provide the following information.

Full Legal Name / Location / Percent Ownership / Indemnity Available? / Endorsed for Obligation?

G. Have there been any changes in the control or management of the company during the last 5 years?

Yes No

If yes, please explain:

Yes No

H. Continuity of Ownership:

a) Is there a buy-sell agreement in effect?

b) Who are the parties to the buy-sell agreement (give details)?

III. LICENSING INFORMATION AND FEDERAL OR STATE DISBARRMENT

A. Please list all trade and professional licenses, if any, required for you to perform your services. (Attach separate sheet if necessary)

Date of expiration / Name on License / State / License Number

No Yes

B. Has any license ever been denied or revoked?

No Yes

If yes, please describe:

C. Has a complaint ever been filed with a Contractor's State License Board against your firm?

If yes, please explain:

No Yes

D. Is your firm currently barred from any Federal or State work?

If yes, please explain:

IV. WORK EXPERIENCE and OPERATIONS

A. Please complete Attachment “A”, (or your own form containing the same information) which includes a list of up to ten of the major projects your firm has completed in the last three years showing the project name, location, owner, architect/engineer, general contractor, contract amount, the completion date and the contact information for the entity with whom you were contracted.

B. What is your average job size in dollars?

C. What was your largest project ever completed? In what year?

D. What percentage of your work is usually subcontracted to others? %

Types of work usually subcontracted?

E. How many projects have you participated in a BIM process?

Yes No

F. Does your company utilize any BIM software?

Yes No

G. Have you ever completed a LEED Certified Project?

Yes No

H. Do you have a full time QA/QC representative?

If yes, how many: Corporate: Field:

Yes No

I. Do you have a formal written Quality Control Manual/Program?

J. Please furnish the following information for the 3 largest projects on which your firm is currently working:

Project #1 / Project #2 / Project #3
Project Name
Contract Price
Location
Owner
% Complete
Scheduled Completion
General Contractor
Name for GC Reference
Title
Email
Phone Number

V. REFERENCES

List five current major suppliers or lower tiered subcontractors (NOTE: Reference Name and Phone number should be for the person that can provide payment history):

Company Name / Name of Person to Contact for Reference / Email
1)
2)
3)
4)
5)

VI. SAFETY AND HEALTH

Please attach the following to this form:

1. Your OSHA 300A Form for the past three years.

3 yr avg Recordable Incident Rate 3 yr avg Lost Time Incident Rate

2. A letter from your insurance broker confirming your EMR for the past three years.

Current EMR Last Year’s Year before last

Yes No

A. Do you have a full time Safety Director?

Yes No

B. Do you require annual Safety Training for Field Supervisors?

C. Number of work related fatalities in the past three years.

D. Number of OSHA citations in the past 3 years.

E. Number of EPA citations in the past 3 years.

Yes No

F. Do you have a drug free workplace policy?

VII. ADDITIONAL INFORMATION

Please attach any additional information you feel will help us determine your firm's qualifications and expertise, including Accredited Quality Contractor Certifications, ISO Certification, etc.

I hereby certify that the above information is accurate, correct and true, and hereby grant permission for Flintco to contact references.

Name:

Title:

Signature

Date:

PRIOR TO RETURNING THIS FORM, ATTACH THE FOLLOWING: (IF SENDING BY EMAIL, PLEASE PRINT, SIGN, AND SCAN WITH ALL REQUIRED ATTACHMENTS IN THE SAME FILE.)

Included

COPIES OF MINORITY OR DISADVANTAGED CERTIFICATIONS IF ANY

ATTACHEMENT “A”LIST OF TEN OF THE MAJOR PROJECTS FOR THE PAST THREE YEARS

OSHA 300A FORM FOR THE PAST THREE YEARS

LETTER FROM YOUR INSURANCE BROKER STATING YOUR EMR FOR THE PAST 3 YEARS

RETURN THIS FORM TO: Email or Mailing Address

IF THIS FORM WAS NOT ISSUED BY AN AREA OFFICE, PLEASE VISIT WWW.FLINTCO.COM TO DETERMINE WHICH AREA OFFICE WOULD BE YOUR PRIMARY CONTACT.

PROCEED TO SECTION VIII – FINANCIAL INFORMATION - IF YOU NEED TO PREQUALIFY FOR SUBCONTRACT AMOUNTS MORE THAN $150,000.

11/07/2012

Section IV
Attachment “A”
Work Experience to Subcontractor Prequalification Form
DATE: / YOUR FIRM'S NAME:
/ Federal Tax ID:
/ Contact Information for Firm on Your Contract
Project Name / Location / Owner / Arch / Eng / Name of Firm with Whom you Contracted / Contract Amount / Completion Date / Name / Phone # / Email

11/07/2012

VIII. FINANCIAL INFORMATION – FED. I.D. #: COMPANY:

This financial information is considered confidential and shall be sent directly to:

Flintco, LLC

ATTN: Charles Strauser, Chief Financial Officer/Senior Vice President

1624 West 21st Street, Tulsa, OK 74107

Voice (918) 587-8451 Email

Any subcontractor whose subcontract is anticipated to be greater than $150,000 shall submit a copy of the firm’s most recent financial statement (audited, if available). As an alternative, you may provide the following information signed and sealed by your CPA on their letterhead:

Your Current Ratio (Current Assets divided by Current Liabilities)
Your Debt to Equity Ratio (Total Liabilities divided by Net Worth)
Ratio of Working Capital/Backlog

4. Ratio of Net Worth/Backlog

Furnish the following reference letters:

1. Banking reference from your bank officer including: line of credit (total and available), overall banking relationship, and years of relationship. If you use more than one bank, only one reference is required.

2. Surety Capacity Letter from your surety broker including: Name of Bonding Company, Bonding Capacity single project, total program bonding limit, years of business relationship, and largest bond provided.

A. Name and contact information for company financial information:

Name of Accounting Firm:

B. Your annual sales volume for the last three (3) years

This Year: / Last Year: / Year Before Last:

No Yes

C. Has your firm or any other organization with which your officers or owners were involved during the past three years, ever failed to complete any work awarded, petitioned for bankruptcy, compromised with creditors, defaulted on a contract, caused a loss to a surety or been terminated for cause?

If yes, please provide a complete explanation.

No Yes

D. Are there any judgments, claims, arbitration proceedings, or suits pending/out-standing against your firm or its officers or principals?

If yes, please provide a complete explanation.

No Yes

E. Has your firm filed any lawsuits or requested arbitration or mediation with regard to construction contracts within the last three years?

If yes, please provide a complete explanation.

F. What is your backlog (uncompleted work under contract) today?

G. Is your company or its principals acting as Guarantor, Indemnifier, or Surety for others, or as endorser on their notes or accounts? No Yes

No Yes

J. Are there any liens for labor or materials filed against your company, its officers or any company associated with them?

I hereby certify that the above information is accurate, correct and true.

Name:

Title:

Signature

Date:

REQUIRED ENCLOSURES:

Financial Statement or CPA letter

Banking Letter

Surety Letter

(IF SENDING BY EMAIL, PLEASE PRINT, SIGN, AND SCAN WITH ALL REQUIRED ATTACHMENTS IN THE SAME FILE.)