| Paradigm General Contractors

Vendor Pre-Qualification Form

Company Information

Company name: *

Street address: *

City: *

State: *

Zip code: *

Phone: *

Fax:

Website:

Contractor license#: *

Federal ID#: *

Contact Information

Name: *

Title:

Phone:

Fax:

Email: *

Affiliations and Company Specifics

Union affiliation: *

Agencies & Certification Numbers

Agency:

Certification#:

Agency:

Certification#:

Agency:

Certification#:

Type of work you do

Supplies you provide

Specify in percentages

Residential: %

Commercial: %

Industrial: %

Other: %

Average sales volume for the last 3 years

Year 1: $

Year 2: $

Year 3: $

Are you bondable?:

Maximum amount: $

Typical contract size:

Your geographical range:

Has your company ever failed to complete a project?: *

If yes, please explain:

Safety and Health

Workers compensation interstate experience modification rate

Year 1:

Experience modification rating:

Year 2:

Experience modification rating:

Year 3:

Experience modification rating:

Has your firm had any OSHA fines or fatalities in the last 3 years?

If yes, please describe:

Insurance

Name of general liability insurance carrier: *

Maximum amount of coverage: *

Including your excess umbrella liability: *

Can you provide insurance for completed operations: *

Please provide three projects completed in the last three years

Project #1

Name:

Location:

Owner:

General contractor:

Contract amount:

Brief project description:

Project #2

Name:

Location:

Owner:

General contractor:

Contract amount:

Brief project description:

Project #3

Name:

Location:

Owner:

General contractor:

Contract amount: $

Brief project description:

Additional information

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