Vendor Selection Form

Classification

Company is a

Services and/or materials offered

Geographical service area(s) – City or states

License Information

Type of License

License Number

State

Type of License

License Number

State

Type of License

License Number

State

Organization

Date of Formation of Corporation

State of Formation

President’s Name

Vice-President’s Name

Secretary's Name

Treasurer’s Name

Name of all of your company's subsidiaries, or parent corporations, all sister corporations and all companies controlled by any of the principals of your company, giving the relationship of each to your company:

Date of Formation of LLC

State of Formation

Name and title of all managers and officers

Name and home address of each member:

Name of all companies controlled by your Company or any of the members:

Date of Formation of Partnership

State of Formation

Partnership is

Name and home address of all partners (indicate any limited Partners) (use separate sheet if necessary):

If an Individual/Sole Proprietor, provide the name of owner and date established:

If your organization is other than those listed above, provide the type of organization and the date established:

Name and address of each principal

Name of all companies controlled by your Company or any of its principals

Bonding Information

Provide a certified letter from your surety company verifying bonding capacity and bonding rate.

Surety Company

Contact

Street Address

City

State/Province

ZIP / Postal Code

Phone

Rating

Bonding Agent

Company

Bonding Limit:

Claims and Suits

Has your organization ever failed to complete any work awarded to it?

Are there any judgments, claims, arbitration proceedings or suits pending or outstanding and unsatisfied against your organization or its officers?

Has your organization filed any law suits or requested arbitration with regard to construction contracts within the last five years?

Within the last five years, has any officer or principal of your organization ever been an officer or principal of another organization when it failed to complete a construction contract?

Minority Business Enterprise Status

What is your Minority business enterprise status?

Certified By:

If checked "Other," please explain

Has this Company been indebted to or made application for a loan from a Small Business Administration within the past 24 months?

Safety

What is Company’s current Experience Modifier Rate (EMR):

Year

Does your Company have a written OSHA compliant safety program?

Does your Company have a written Drug Abuse Policy which includes pre-hire, random, and post-accident drug testing?

References

List three general contractors and project owners for trade references.

List three suppliers/vendors that you buy material from on a regular basis.

I certify that the information above is accurate and true. It is also understood that any misleading and/or false statements contained herein may disqualify the Company and/or be sufficient cause for termination of any contract, agreement or work assignment awarded by Pulice Construction, Inc.YES

Classification

Company Information

License Information

Organization

Bonding Information

Provide a certified letter from your surety company verifying bonding capacity and bonding rate.

Claims and Suits

Minority Business Enterprise Status

Safety

References