Referred by

FAIS Contact:
FAIS Project:
Have you worked with FAIS before?
Yes
No

General Information

Company:
Address:
City:
State:
Zip Code:
Phone:
Fax:
Email:
Website:
Federal ID Number:
Year Business Started:
Main Contact:
Contact Title:
Union
Yes
No

Subcontractor
Vendor/Supplier

Contractor's Licenses(s), States and Numbers

State Contract Number Exp Date


Organization

Business Type:
Corporation
Partnership
Limited Liability Company
Sole Proprietor
Joint Venture
Name Title Number of
Years w/ Co.		 % Ownership

Provide name of parent company:
Provide number of:
Office Staff:
Field Supervisors:
Average Field Labor:
Average Shop Labor:

Check applicable certification(s): (attach copies of certifications for each qualifying SBA classication)
Large business (no special classification)
Minority Business Enterprise (MBE)
HUBZone Small Business
Small Disadvantages Business (SDB)
8(a) Certified Small Disadvantage Business
Small Disadvantages Business (SDB)
Native American / Indian Tribe
Small Business Enterprise (SBE)
Veteran Owned Small Business (VOSB)
Service Disabled Veteran Owned Small Business (SDVOSB)
Women Owned Small Busines (WOSB)/(WBE)
Alaskan Native Corporation (ANC)
Other:

Legal Information

Are there any judgements, claims, arbitration proceedings or suits pending/outstanding against your firm, its officers, or principals?
Yes (If yes, please attach a complete explanation)
No

Has your company filed any lawsuits or requested arbitration or mediation with regard to construction contracts within the last three (3) years?
Yes (If yes, please attach a complete explanation)
No

Has your company or any organization with which your officers were involved during the last three (3) years ever been in bankruptcy or a voluntary or involuntary reorganization?
Yes (If yes, please attach a complete explanation)
No

Financial Information

Annual Volume
What was the average annual revenue from work completed in the last five (5) years and what is next year's forecasted revenue?

Year:  Revenue: 
Year:  Revenue: 
Year:  Revenue: 
Year:  Revenue: 
Year:  Revenue: 
This Year:  Forecasted Revenue: 
To prequalify for a contract of any value, attach copies of your most recent annual financial statements (balance sheet, income statement and cash flow, as well as a current work report). If your annual statements are more than six months old, please also include your most recent quarterly statement. FAIS uses this information strictly for prequalification purposes and will not disclose this information to any third parties.

Safety

OSHA Record
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 inspections, standards cited, violation type, 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:
Employee hours worked the last three years:

OSHA 300 Log Information (list the last three years of information shown below)
Year:
No. of Fatalities:
No. of Cases Days Away from Work:
No. of Job Transfer or Restriction:
No. or Other Recordable Cases:

Does your company have written safety program?
Yes (If yes, please attach)
No

Experience

Trade Categories
Please list the primary categories of work your firm performs.






In what states do you work:

Preferred contract size:
Up to $250,000
Up to $500,000
Up to $1,000,000
Up to $5,000,000
Over $5,000,000

Please attach a list of any other branch office locations.

Contract Method
Please indicate the percentage of your work load for each contract method.
Competitive Bid:
Negotiated/Design Assist:
Design Build:
IPD:

Performance References

Provide four references below. Each reference should be from a different general contractor.  These references should be for work completed in the last five years and should be representative of the work you are trying to prequalify for now.  One must be for your largest project within the last two years.  Note: The contract provided must have direct knowledge of your performance on that project.  Leaving out any requested contact information including email address will delay processing of your form.

Largest Project in the last two years:
Project Name:
General Contractor:
Subcontract Value:
Contact Name:
Contact Email:
Contact Phone:
Contact Fax:

Project 2:
Project Name:
General Contractor:
Subcontract Value:
Contact Name:
Contact Email:
Contact Phone:
Contact Fax:

Project 3:
Project Name:
General Contractor:
Subcontract Value:
Contact Name:
Contact Email:
Contact Phone:
Contact Fax:

Project 4:
Project Name:
General Contractor:
Subcontract Value:
Contact Name:
Contact Email:
Contact Phone:
Contact Fax:

References

Banking

Name:
Contact:
Phone:
State:
Zip Code:
Since:


Bonding (attach formal letter from bonding company)

Bonding Company:
Surety Broker/Agent:
Contact Person:
Phone:
Time with Bond Co.:
Bond Capacity per Project:
Aggregate:
Bond Co. Rating:
Last Bond Issued:
Date:
Amount:
Rate %:


Insurance (attach current copy of insurance certificate)

General Liability Carrier:
Effective:
Expiration:
Limit:
Insurance Broker/Agent:
Phone:


Please provide Dunn & Bradstreet Number:

1. Supplier Name:

Location:

Contact Name:

Phone:

2. Supplier Name:

Location:

Contact Name:

Phone:

3. Supplier Name:

Location:

Contact Name:

Phone:

Additional Information
Please attach my additional information to help us determine your company's qualifications and expertise.

Comments:
Signature
By submitting this form, I certify that the information provided therein is accurate, correct, and true.  By submitting a valid bid, the subcontractors or vendor authorizes FAIS to obtain a written or oral credit report on the subcontractor's or vendor's business entity from any credit-reporting agency.  The subcontractor or vendor has current or inactive experience to give any and all necessary information to FAIS, which will assist FAIS in the subcontractor/vendor evaluation.  The subcontractor or vendor further authorizes FAIS to re-investigate the status from time-to-time, as FAIS deems necessary.

Name:
Date:
Title:
Phone:

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