Please Fill out the Prequalification form for access to the online bid center:
If you would prefer to print the form and submit it by fax, please send it to: 203-630-1998

Items listed in RED are REQUIRED

For the purposes of this document, "you", "your", "your company", "company" and "your business"
all refer to the applicant company that is listed in the "Company Name" field.

GENERAL INFORMATION

Company Name:    

Other Names your Business Operates Under:





Company Type:

If incorporated, State of Incorporation:   Date of Incorporation:

Phone:                 
Fax:                    
e-mail:                

Website Address:

Mailing Address:   
City:                        State:       Zip:  


Street Address
(if different):        
City:                        State:       Zip:  

CONTACT INFORMATION
Contact Person 1: Phone:    Fax:
                  Email:

Contact Person 2: Phone:    Fax:
                  Email:


States Where Your Company Does Business:
 1:

2:

3:

AREAS OF CONNECTICUT WHERE YOUR COMPANY WILL WORK (Please select all that apply):

   
  


Please list any towns to be excluded from your service area:


Year Company Started:


SBE     Certification Number:     Certifying Agency:
WBE     Certification Number:     Certifying Agency:
MBE     Certification Number:     Certifying Agency:
DBE     Certification Number:     Certifying Agency:


Number of Employees:
Home Office:     Field Supervisory Employees:      Trades-People:     TOTAL:


TRADE / INDUSTRY INFORMATION:
 Please Select your Industry Specification Code and Trade from Below:
Please Select all that apply. If you select "Other" Please explain in
The "Other" Section Below:











OTHER:




SAFETY:

 What is/are your Standard Industry Code(s): 1: 2: 3: 4: 5:
* If you do not know your SIC code(s), please look it/them up HERE

Do you have a person who's job is specifically dedicated to safety at your company? YES       NO

Do you have a written safety policy?   YES       NO

Would you be willing to provide your safety policy in print if requested? YES       NO

What is your current EMR (ModRate):

In the past three (3) years, Have you been cited and/or fined by OSHA?
 YES       NO



In the past three (3) years, Have you been cited and/or fined by the EPA?
 YES       NO


Licensing and Tax Information:

Contractor License Number:       State:      Exp. Date:

Federal Tax ID Number:
    Number:     State:


Legal Information:

Has your company or any of its principals ever been petitioned for bankruptcy, failed in business,
defaulted or been terminated on a contract awarded to you?
 YES     NO


Have any of the principals of your company ever been indicted
or convicted of any felony or other criminal conduct?
YES     NO


Has your company ever been disbarred or otherwise precluded from
pursuing public work or ever been found to be non-responsive by a public agency?
 YES     NO


Has your company ever had a claim made against it for improper, delayed, defective, or
non-compliant work or failure to meet warranty obligations
YES     NO


Is your company or any of its principals or major shareholders
currently involved in any arbitration or litigation?
 YES     NO


Does your company have any outstanding judgments or claims against it?
YES     NO


Has your company ever failed to complete any work awarded to it?
 YES     NO


Please list any litigation brought against your Company in the past
five (5) years that asserts that you failed to make payments to anyone:


Unions / Trade Associations:

 Union Membership(s):

Union Local Number         Union Name                   Agreement Expiration Dates  
                     
                     
                     


Trade Associations:

Trade Association Name:







Bonding Information:

 Surety Company Name:            
Surety Broker Name:            
Bonding Capacity per Job:       $
Aggregate:                                $

Date of Last bond:               Bond Rate:

Persons or Entities who provide indemnification:

Bonding Contact Address:         City:
                                State:       Zip:

Bonding Contact Name:           Phone:      
                                email:


Company Project Information:

Minimum Project Size You are willing to work on:
$

Maximum Project Size You are willing to work on:
$
Largest Project Completed by Your Company:
Project Name                                        Year            Contract Amount
            $


Average Annual Volume of work performed in the last three years: $

At what project size is your company most efficient?


           
Will your company work on prevailing wage jobs?   YES       NO


Which Types of Projects do you have experience working on? (Please check all that apply)

 Single and Multi-Family Residential Projects
Commercial Projects (Offices, Stores, etc)
Industrial / Warehouse Projects
Healthcare / Senior Living
Religious Facilities
Academic Facilities / Higher Education
Community Facilities (Cultural / Community Centers)
Historic Renovation/Restoration Projects
Municipal Facilities (Police / Fire Stations, Government Facilities)


 REFERENCES:
Please provide references for your Company in the following categories:


MAJOR SUPPLIER REFERENCE:

Company                        Address                             City                              State           Zip
                       

Contact Name                               Contact Phone
           




OTHER SUPPLIER REFERENCE:

Company                        Address                             City                              State           Zip
                       

Contact Name                               Contact Phone
           




TRADE REFERENCE:

Company                        Address                             City                              State           Zip
                       

Contact Name                               Contact Phone
           




CLIENT REFERENCE:

Company                        Address                             City                              State           Zip
                       

Contact Name                               Contact Phone
           



DO YOU HAVE ANY QUESTIONS OR COMMENTS?




I certify that all of the above information is true and
sufficiently complete so as to not be misleading.

Name / Signature of person filling out this form: