Contractor's Questionnaire

Submitted By

First NameLast Name

Email

example@example.com

Phone Number

Format: (000) 000-0000.

Full Corporate Name?

Are there other Trade Names or Assumed Names (d.b.a)?

Has your organization previously operated under any other names?

Does the business have any subsidiaries or affiliates or related entities? If yes, please explain:

How many years has your organization been in business as a Contractor?

Has there been a change to ownership in the past two years? If yes, please explain:

Type of Business

State of Incorporation

Incorporation Date

MonthDayYear

Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Web URL

Does your business use a payroll service for its employees?

Are you a member of any trade associations (e.g. American Subcontractor's Association)? If yes, which one(s):

Have the owners, officers or key managers of the company ever been convicted of a felony?

Have the owners, officers or key managers of the company ever filed for bankruptcy? If yes, please explain:

Federal Tax ID

Are there past due Federal or State taxes including but not limited to withholding taxes? If yes, please explain:

If so, has a lien been filed against the business or the owners

What type of work do you perform?

What type of work do you SELF perform?

What type of work do you SUBCONTRACT out?

Have you or any of your companies ever sued anyone or been sued in Court?

The name(s) of adverse parties?

The years in which the lawsuit(s) are/were pending?

The Court where the case was filed (State and County)?

The outcome of the lawsuit:

Are there any judgments, claims, arbitration proceedings or suits pending or outstanding against your organization or its officers? If so, please explain:

Have you or any of your companies ever been terminated for cause on a construction project? If so, please explain:

The name(s) of the part(ies) that terminated you:

The name(s) and location(s) of the project:

The basis of the termination and whether you believe the termination was wrongful:

Have you ever had liquidated damages imposed upon you or any of your companies? If so, please supply:

The name(s) of the party that imposed the liquidated damages:

The name(s) and location(s) of the project:

The basis for the liquidated damages and whether you believe the liquidated damages were wrongful:

Has your organization ever failed to complete any work awarded to it? If so, please explain:

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?

What is your policy and procedure for sending Notices to Owner on a new project. Do you prepare the Notice to Owner in-house or do you use an outside service?

Who is responsible in your office for making sure a Notice to Owner was sent?

OPTION 1: Please state what insurance coverages and limits your company carries.

OPTION 2: Insurance Certificate Upload

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What is your Workers' Compensation Safety Modifier (if known)?

Have you ever obtained a bond for a construction project? If so, please supply:

The name(s) of the bonding company:

Whether the bond is still active:

Whether any other person or entity has ever made a claim against the bond(s):

Accounts Receivable (A/R) Balance ($)

Accounts Payable (A/P) Balance ($)

Are the current accounts receivable pledged as collateral to any third party? If yes, please explain:

Balance Sheet, Income Statement, A/R & A/P Agings, 3 Months of Bank Statements

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We will take partial applications, but please fill out to the best of your ability.

Name

First NameLast Name

Date of Birth

DayMonthYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Title

ex: President, CFO, etc

SSN

We will either need your SSN or Driver's License Info

Driver's License #

We will either need your SSN or Driver's License Info

State of Issuance

Image of Driver's License

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% Owned of Company

Is there more than one principle?

Name

First NameLast Name

Title

ex: President, CFO, etc

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

DayMonthYear

SSN

We will either need your SSN or Driver's License Info

Driver's License #

We will either need your SSN or Driver's License Info

State of Issuance

Image of Driver's License

Browse Files

% Owned of Company

Is there more than two principles?

Name

First NameLast Name

Title

ex: President, CFO, etc

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

DayMonthYear

SSN

We will either need your SSN or Driver's License Info

Driver's License #

We will either need your SSN or Driver's License Info

State of Issuance

Image of Driver's License

Browse Files

% Owned of Company

Are there more than 3 principles?

Please list the additional principles and their respective ownership:

Disclaimer

Applicant understands that Greenback Capital and its Service Providers will rely upon the foregoing information in determining whether to enter into a financing agreement and applicant authorizes Greenback Capital and Service Providers to do so. Applicant also understands that the foregoing information may be incorporated by reference into an agreement between Applicant and Greenback Capital and any failure of Applicant to disclose truly, completely and correctly the information requested may constitute a breach of any such agreement. Applicant understands further that Greenback Capital has not, by requesting the completion of or accepting this application form, committed to make or implied an intention or commitment to enter into a financing program with Applicant. Applicant acknowledges that he has retained a copy of this application. "Applicant" hereby authorizes Greenback Capital and/or its Service Providers (officers, employees, or other representative thereof) to visit and inspect any properties of Applicant; to discuss Applicant and its affairs, finances, and accounts with, and be advised as to the same by Applicant's officers, employees, and independent public accountant; all to such reasonable extent as Greenback Capital may desire, and all on the condition that Greenback Capital seeks such information in good faith in connection with financing the Applicant. Applicant hereby authorizes its suppliers, customers, lenders, accountants, principals, officers, and attorneys to provide Greenback Capital (and any officer, employee, service provider, or representative thereof) such information about Applicant and its affairs, finances, and accounts as Greenback Capital may request. Applicant also authorizes each such person and firm to accept a copy of this Authorization as if it were an original. The undersigned individual(s) who is/are either a principal(s) of the credit applicant or a sole proprietorship of the credit applicant, recognizing that his or her individual credit history may be a factor in the evaluation of the credit history of the applicant, hereby consents to and authorizes the use of a consumer credit report on the undersigned by Greenback Capital and/or its service providers from time to time as may be needed in the credit evaluation.

Today's Date

Date

Print Name

Please type your full legal name

Signature

Please verify that you are human

Contractor's Qualification Questionnaire

General Information

Tax Information

Scope of Work

Claims & Suits

Notices to Owner

Insurance & Safety

Payment or Performance Bonds

Financial

Document Upload

Ownership

Principal #1

Principal #2

Principal #3

Submission