Contractor's Qualification Questionnaire
We can accept incomplete forms. Please note, you can always go back and edit a form after your initial submission.
Submitted By
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First Name
Last Name
Email
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example@example.com
Phone Number
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General Information
Full Corporate Name?
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Are there other Trade Names or Assumed Names (d.b.a)?
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Yes
No
Has your organization previously operated under any other names?
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Yes
No
Does the business have any subsidiaries or affiliates or related entities? If yes, please explain:
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Yes
No
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:
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Yes
No
Type of Business
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C-Corporation
Partnership
LLC
Sole Proprietor
S-Corporation
State of Incorporation
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Incorporation Date
*
/
Month
/
Day
Year
Date Picker Icon
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Web URL
Does your business use a payroll service for its employees?
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Yes
No
Are you a member of any trade associations (e.g. American Subcontractor's Association)? If yes, which one(s):
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Yes
No
Have the owners, officers or key managers of the company ever been convicted of a felony?
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Yes
No
Have the owners, officers or key managers of the company ever filed for bankruptcy? If yes, please explain:
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Yes
No
Tax Information
Federal Tax ID
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Are there past due Federal or State taxes including but not limited to withholding taxes? If yes, please explain:
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Yes
No
If so, has a lien been filed against the business or the owners
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Yes
No
Not Applicable
Scope of Work
What type of work do you perform?
What type of work do you SELF perform?
What type of work do you SUBCONTRACT out?
Claims & Suits
Have you or any of your companies ever sued anyone or been sued in Court?
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Yes
No
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:
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Yes
No
Have you or any of your companies ever been terminated for cause on a construction project? If so, please explain:
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Yes
No
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:
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Yes
No
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:
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Yes
No
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?
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Yes
No
Notices to Owner
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?
Insurance & Safety
OPTION 1: Please state what insurance coverages and limits your company carries.
OPTION 2: Insurance Certificate Upload
Browse Files
Cancel
of
What is your Workers' Compensation Safety Modifier (if known)?
Payment or Performance Bonds
(If applicable)
Have you ever obtained a bond for a construction project? If so, please supply:
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Yes
No
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):
Financial
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:
*
Yes
No
Document Upload
Balance Sheet, Income Statement, A/R & A/P Agings, 3 Months of Bank Statements
Browse Files
We will take partial applications, but please fill out to the best of your ability.
Cancel
of
Ownership
Principal #1
Name
*
First Name
Last Name
Date of Birth
/
Day
/
Month
Year
Date Picker Icon
Address
Street Address
Street Address Line 2
City
State / 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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Image of Driver's License
Browse Files
Cancel
of
% Owned of Company
Is there more than one principle?
Yes
No
Principal #2
Name
First Name
Last Name
Title
ex: President, CFO, etc
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
/
Day
/
Month
Year
Date Picker Icon
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Image of Driver's License
Browse Files
Cancel
of
% Owned of Company
Is there more than two principles?
Yes
No
Principal #3
Name
First Name
Last Name
Title
ex: President, CFO, etc
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
/
Day
/
Month
Year
Date Picker Icon
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Image of Driver's License
Browse Files
Cancel
of
% Owned of Company
Are there more than 3 principles?
Yes
No
Please list the additional principles and their respective ownership:
Submission
Please acknowledge and submit.
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.
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