Subcontractor/Supplier Application

Subcontractor/Supplier Application

Please fill out the form below and we will get back to you as soon as we can.
 
1. Subcontractor Information
Company Name *
DBA *
Physical Address *
City *
Select a State *
ZIP *
Phone *
Fax *
Primary Contact *
E-mail *
Payment Address *
City *
Select a State *
ZIP *
AR/Billing Contact *
Phone *
Email *
2. License Information
License Number *
Select a State *
Type of Work *
Federal Tax ID *
Current Classification *
Prevailing Wage Experience? *
If yes, provide description of experience *
Are you signatory with any Unions? *
If yes which ones? *
3. Additional Information
Type of Organization *
Year organization established *
Other Business Names *
Owner(s) *
Names of Officers or Principals *
4. Safety
Safety Officer *
Phone *
E-mail *
Do you have a written Safety & Substance Abuse Policy? *
Do you conduct documented Safety Meetings? *
How often are meetings conducted? *
Do you have a New Hire Safety Orientation *
Are subcontractors and suppliers included in safety meetings? *
How often do Field Supervisors conduct safety meetings? *
Current Number of Employees *
Current Number of Field Employees *
Current Number of Office/Shop Employees *
Workers Comp EMR/ERP Rate:
2016 *
2016 *
2015 *
In the last 5 years how many OSHA or OSHA State Plan inspections has your company had? *
How many inspections resulted in a Violation(s)/Citation(s) being issued? *
Please explain actions taken to prevent these violations from reoccurring *
5. Financial Information
Bank Name *
Address *
City *
Select a State *
ZIP *
Phone *
Primary Contact *
E-mail *
CPA Firm *
Address *
City *
Select a State *
ZIP *
Phone *
Contact *
E-mail *
Insurance Agency *
Address *
City *
Select a State *
ZIP *
Phone *
Primary Contact *
E-mail *
Years with Agent *
Bonding Company *
Address *
City *
Select a State *
ZIP *
Phone *
Primary Contact *
Bonding Capacity-Single Job *
Bonding Capacity-Aggregate *
E-mail *
Workers Comp and Employers Liability *
Carrier *
Policy Form *
Policy Number *
Policy Period *
Claims Paid in the Last 5 Years *
6.Bidding / Estimating information
Section block text
Primary Contact *
Phone *
Fax *
E-mail *
Indicate preferred project sizes *
What market segment do you typically work in? (select all that apply) *
Other market Segment *
Which project types do you typically work on? *
List scopes of work you perform *
7. Legal
Have liquidated damages been assessed for late completion of any project? *
If yes, please attach explanation *
Has your company or any of its principals ever petitioned for bankruptcy, failed in business, defaulted, or been terminated on any contract awarded? *
If yes, please attach explanation *
Have any of the owners, officers, or major stockholders of your company ever been indicted or convicted of any felony or other criminal conduct? *
If yes, please attach explanation *
8. Please attach all of the following documents:
(1) Contractor Score Certificate dated within 6 months (2) Letter from Bank indicating all credit and deposit holdings (3) Letter from Surety/Bonding Agent indicating Individual and Maximum Bonding Capacity *Only one upload available, please zip all documents.
Zip Upload *
I/We have attempted to answer all questions in a full and complete manner to assure that our answers are not in any respect misleading, either by expressing ourselves in a misleading or ambiguous manner or omitting information. I/We recognize that JR Abbott Construction, Inc. will be relying on the accuracy of the information and our responses in this questionnaire and in deciding whether to permit us to bid and to award work to our Company.
Signed (by an Officer of the Company) *
Date *
Name of Company *
Completed By *
Title *
This contractor and subcontractor shall abide by the requirements of 41 CFR 60-1.4(a), 60-300.5(a) and 60-741.5(a). These regulations prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with dis