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MCM > Doing Business with MCM > sub-contractor pre-qualification form

Subcontractor Pre-qualification Form

You must complete all the required fields (*) before submitting this application. Please Don't use single colons ( ' ) on the Form. NOTE: In order to use this Form JavaScript must be Enabled on your Browser.

Date:

Company Information

1. Company Name: *

2. Phone Number: *

3. Contact Name: *

4. Contact Title: *

5. Mailing Address: *

6. Headquarters Address: *

Email *

7. Other branch addresses if applicable:

8. Tax ID # / FEIN: *

9. D&B #:

10. How many years has your company been in operation? *

11. Please specify type of business entity (i.e. Corporation, Limited Liability Company or other): *

If a Corporation, please mention State of Incorporation:

12. Does your company operate under any other business name currently or in the past? *

13. Is your Firm Affiliated with any other company?

Firm Name:

Phone:

Address:

If yes, please list all applicable names below:

Other Company Names:

14. Has your firm done business with MCM before under current or any other name? If yes, please list all applicable names below: *

Other Company Names:

15. Current number of payroll employees:

16. Is your labor force part of a union? *

If yes, mention what union (s):

17. Does your company have a Minority/Small Business Status? *

SMALL BUSINESS AND FEDERAL CONTRACTS SECTION

PLEASE UPLOAD ALL APPLICABLE MINORITY CERTIFICATIONS TO THIS FORM (FORM MUST HAVE THE “UPLOAD FILE FEATURE”)

UPLOAD CERTIFICATIONS:

1a. Check all that apply:

Small Business

8a Program

SDB

WOSB

VOSB

SDVOSB

HUBZone

DBE

CSBE

W/DBE

B/DBE

H/DBE

SDE

Other

Please specify: *

1b. If you have performed work for any Federal agency, please check all that apply:

Congress

Department of Commerce

Department of Defense

Department of Energy

Environmental Protection Agency

General Services Administration

Housing & Urban Development

Library of Congress

NASA

Office of Management & Budget

Small Business Administration

USPS

Veteran Affairs

Other

Please specify: *

1c. List up to four references

Contact Name:

Phone:

Contact Name:

Phone:

Contact Name:

Phone:

Contact Name:

Phone:

2. Please provide the North American Industrial Classification System (NAICS) Code(s) that best describes your business. Please provide at least one but no more than six codes should be entered for core business operation only.

check

By checking this box I am certifying that all information above is true and correct

COMPANY EXPERIENCE:

1. Please specify the type and size of work that your company has been historically involved with:

SMALL (less than $550k)

MEDIUM (more than $550k)

LARGE (more than $2 Million)

Airports

small

medium

large

Hospitals

small

medium

large

Schools

small

medium

large

Higher Education

small

medium

large

Roads/Bridge/Highways

small

medium

large

Retail

small

medium

large

Mixed-use

small

medium

large

Office

small

medium

large

Light Industrial

small

medium

large

Heavy Industrial

small

medium

large

Other, please specify:

2. List section /description of work your company performs by order of magnitude:
(Type N/A for no answer)

CSI Specification: *

Description of Section: *

Applicable Manufacturers: *

3. List Licenses Contractor holds and state of operation:

Number: *

Trade: *

4. List additional applicable licenses or other County Licenses and/or certification:

5. We normally perform % of the work with our own forces.

6. List manufacturers for whom you are licensed distributor and / or products that you manufacture

7. List major construction projects your organization has in progress by order of magnitude.

Project Name:

Project Name:

Project Name:

Project Name:

Project Name5

Contract Amount:

Contract Amount2

Contract Amount3

Contract Amount4

Contract Amount5

Percent Complete:

Percent Complete2

Percent Complete3

Percent Complete4

Percent Complete5

Completion Date:

Completion Date2

Completion Date3

Completion Date4

Completion Date5

Owner/Architecht Name/Phone:

Owner Architecht2

Owner Architecht3

Owner Architecht4

Owner Architecht5

8. Has your firm ever defaulted or ever failed to complete any work awarded? If yes, explain why in the space below.

FINANCIAL DATA

1. Indicate the highest subcontract value your firm wishes to be considered for:

Please Note: Contractor must be able to bond amount of contract considered below.

2. Name of Surety?

Bonding Agent:

Phone:

Address:

a. Maximum Bonding capacity for single job?

b. Total bonding capacity?

Do you have insurance? If yes please provide coverage type:

3. Total value of active Contracts?

4. Average (latest three years) yearly volume of work completed.

year1

value year1

year2

value year2

year3

value year3

SAFETY RECORD AND PROGRAM

emr year1

=

emr year v1

emr year2

=

emr year v2

emr year3

=

emr year v3

emr year4

=

emr year v4

emr year5

=

emr year v5

emr year6

=

emr year v6

2. Number of employee hours worked (Do not include any non-work time even if paid.)

srp_hours worked

srp hours worked2

srp hours worked3

3. Please, calculate incidence rate (I.R) for each year for each year record able and lost time accidents using the following formula:

N= Number of cases from OSHA Log N x 200,000
Employee Hours Worked (given year) = I.R.

Show I.R

4. Do you have a safety officer/department in your company?

5. Do you have a written safety program?

If the answer is yes, make program available for inspection upon request.

6. Do you have a drug and alcohol policy?

If the answer is yes, make program available for inspection upon request.

7. Do you have in place a safety orientation program for new employees?

If the answer is yes, make program available for inspection upon request.

srp checked end *

ALL INFORMATION SUBMITTED IS HELD IN STRICT CONFIDENCE. BY CLICKING IN THE BOX YOU HEREBY CERTIFY THAT ALL THE FOREGOING STATEMENTS CONTAINED HEREIN ARE TRUE AND CORRECT.

AUTHORIZED SIGNATURE: *

Please provide authorized full name

Contact Title: *

Date: *

Year

Month

Day

Leave this field blank

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

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