Subcontractor Prequalification Statement

SUBCONTRACTOR PREQUALIFICATION STATEMENT

Company Name: Date:

Entity (Circle One): Corp Partnership LLP Sole PropFEIN or SS#:

Physical Address:

Mailing Address:

Phone:Fax:

Contact:

Years in Business under present name:

Normal Counties of operation:

E-Mail Address:

LICENSING: Attach copy(s) of your current license(s) as required by State/County/Municipalities for the work you propose to bid.

INSURANCE: Attach samples of your current certificates of insurance for:

1) Commercial General Liability

2) Commercial Auto Owned Hired/Non Owned

3) Florida Workers Compensation.

4) Fidelity Bond

WORK INTEREST

Which CSI Specification Section (s) are you interested in bidding?

Section No: Section Description:

CONTRACTOR LICENSING

Attach current copies of Florida DBPR licenses (if applicable):
Provide your Primary Qualifying Agent’s Florida DBPR License Information:

Last Name: First Name:

Licensing Board: License Type: License #:

CURRENT REFERENCES

List your Company’s two (2) most significant projects currently under construction.
Preferred contact person for these two (2) projects is either the Project Manager or the General Superintendent.
Verify the contact person’s telephone number is correct. (Jobsite telephone number and/or cell phone numbers are preferred)

Project No. 1

Name of Project:Location:

Your $ Subcontract Amount:Scheduled Completion Date:

Contractor:

Contact Person:

Telephone:

Project No. 2

Name of Project:Location:

Your $ Subcontract Amount:Scheduled Completion Date:

Contractor:

Contact Person:

Telephone:

PAST REFERENCES

List your Company’s three (3) most significant projects within the past year.

2. Preferred contact person for these three (3) projects is either the Project Manager or the

General Superintendent.

3. Verify the contact person’s telephone number is correct. (Jobsite telephone number

and/or cell phone numbers are preferred)

Project No. 1

Name of Project:Location:

Your $ Subcontract Amount:Scheduled Completion Date:

Contractor:

Contact Person:

Telephone:

Project No. 2

Name of Project:Location:

Your $ Subcontract Amount:Scheduled Completion Date:

Contractor:

Contact Person:

Telephone:

Project No. 3

Name of Project:Location:

Your $ Subcontract Amount:Scheduled Completion Date:

Contractor:

Contact Person:

Telephone:

PERSONNEL

Indicate total number of permanent staff currently employed directly by your company:

Executive:Skilled Craftsmen:

Supervisory:Unskilled Labor:

List any other sources of sources of skilled/unskilled labor:

What percentage of work do you typically perform with your Company’s forces?

Which activities does your Company typically subcontract? (List)

Is your firm a minority certified business? Yes No

Type of certification: MBE WBE DBE SBE HBE

Classification certified by:

States certified by:Counties certified by:

Cities certified by:

List your experience modification rate (EMR) for the last Three years:

Year:2010Rate:

Year:2009Rate:

Year:2008Rate:

Number of OSHA recordable incidents over the prior 3 years:

(Data available at

Do you have a written Safety Program? Yes No

Are all employees trained in Safety requirements? Yes No

Do you have a Company Safety Director or other Safety Professionals on staff?

Yes No

If Yes, Contact Name:

Phone#:

List Data for Three most recent completed Fiscal Years:

Year:2010

Max. Contract Value Completed:

Annual Company Revenue:

Current Yr Company Workload:

Year:2009

Max. Contract Value Completed:

Annual Company Revenue:

Current Yr Company Workload:

Year:2008

Max. Contract Value Completed:

Annual Company Revenue:

Current Yr Company Workload:

Major Supplier References: (List Three current Supplier References)

Company Name:Address:

Contact:Phone#:

Company Name:Address:

Contact:Phone#:

Company Name:Address:

Contact:Phone#:

Bank References:

Financial Institution:Address:

Contact:Phone#:

Established line of Credit: Yes No

Is your company bondable? Yes No

Bonding Company:

Bonding Capacity: Total:Per Job?

Value of work presently bonded?

Contact Name:

Surety Company:

Has your Organization ever failed to complete any work awarded to it? ______

Are there any Judgements, Claims, Arbitration Proceedings or Suits

Pending or outstanding against your Organization or its Officers? ______

Has your Organization filed any Lawsuits or requested Arbitration with

Regard to Construction Contracts within the last five(5) years? ______

Has your Organization or Its Principals ever filed for Bankruptcy? ______

Please fill out and return attached W-9 form if you have not previously worked for The Angelo Group.

PLEASE ATTACH LAST TWO (2)YEARS OF AUDITED FINANCIAL STATEMENTS (Include Balance Sheets, Income Statements and Opinion Letter from Accountant)

The undersigned certifies that the information provided herein is a clear and accurate representation of this organization.

Information Supplied By:

Company NameSEAL

Print Name

Signature

TitleDate

END

11363 San Jose Blvd.  Building 300 Jacksonville, FL 32223  904-268-2247  Fax 904-268-9931  CGC 049926