Pre-Qualification Form "*" indicates required fields 1. Basic Company InfoCompany Name*DBA (if applicable):Business Type (LLC, Corp, Sole Proprietor, etc.):*Years in Business:*Office Address:*Website:2. Contact InfoMain Contact Name:*Phone Number:*Email Address:* 3. Trade & Coverage AreaTrade(s) or Scope of Work:*Geographic Area Served:*4. Licensing & CertificationsContractor License Number(s) and Issuing State:*Upload Copy of License (optional)Max. file size: 64 MB.Certifications (check all that apply) MBE WBE DBE Other Other5. Insurance SummaryDo you have General Liability Insurance?* Yes No Do you have Workers’ Compensation Insurance?* Yes No Upload Certificate of Insurance (optional)Max. file size: 64 MB.6. Safety InfoEMR (last year)Do you have a written safety program?* Yes No 7. Project ExperienceTypical Project Size Range ($)*Largest Project Completed ($)Upload Portfolio or Project List (optional) Drop files here or Select files Max. file size: 64 MB. 8. References (Optional)Reference NameCompanyPhone/Email:9. SignatureFull Name (Typed)*Consent* I certify the information provided is accurate and complete.*Date* MM slash DD slash YYYY Δ
