Dale Corp Pre-Qualification

Upload latest W9 here *

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Company Information *

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Company Name
Address
Business Phone
Business Fax
FEIN

Company Formation

Formation Date *

State of Formation *

Company Officers, Owners, Partners, Members, and/or Major Shareholders *

	Name	Title	Years in Position	Total yrs of exp.	Authorized Signor (Y/N)
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Contact Information (please provide contact persons for the following areas) *

	Title	Name	Email
Executive
Safety & Health
Accounting
Estimating

Employee History *

	Main Office	Field Supervisory	Trades People	Other	Total
Current # of Employees
Three (3) Year Avg. # of Employees

Have you worked with Dale Corp in the last five (5) years? *

Yes No

Other / Previous names operated under / Sister company *

Any additional information about your company that you wish to share (i.e. complicated JV structure, add'l officers, etc.)

Largest Contracts *

	Largest Current Contract	Largest Contract in Last (3) years
Project Type
Project Name
Owner
Scope Description
Subcontract Value
Bonded (Y/N)
Completion Date

What is your project backlog as of the date of this submission? (Dollars & Months) *

What is your project backlog as of your last financial statement? (Dollars & Months) *

What was your project backlog as of 12 months ago? (Dollars & Months) *

What is your largest incomplete backlog? (Please provide year & Dollars) *

Typical Contract Range *

	Minimum	Maximum
-

Types of Projects (please check all applicable sectors) *

Labor Type *

Union Non-Union Prevailing Rate Furnish Only

Certifications (upload latest of any checked certification)

Small Business Enterprise Women’s Business Enterprise 8a Business Enterprise Minority Business Enterprise Historically Underutilized Business Native American Business Veteran-Owned Small Business Disadvantaged Business Enterprise

Upload Certifications Here

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Provide all phase codes which your company performs per Dale Corp's phase code database (this will be the codes used for solicitation in PROCORE) *

	Phase Code / Description	Phase Code / Description	Phase Code / Description
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Other:

Please share any scopes of work which your company performs that we may not have a phase code for at this time.

License Information *

	State / Locality	License Number	Classification
-
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Labor Agreements

	Trade	National Agreement	Local Agreement	Expires
-
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LEED Accreditation Experience *

N/A Certified Silver Gold Platinum

How many LEED Accredited projects have you completed? *

How many staff personnel are LEED Accredited Professionals (AP)? *

Current Experience Modification Rate (EMR) *

Provide Workers Compensation EMR for the previous three (3) calendar years *

	Last Year	Two Years Ago	Three Years Ago
Year
EMR

Does your company have an alcohol/illegal substance testing policy for the following situations? (check each applicable) *

Pre-Employment Testing Post-Accident Testing Random Testing Other

Does your company employ a full-time representative whose primary responsibility is to oversee Safety, Health & Environment? *

Yes No

How often are field inspections/audits for safety conducted? *

Daily Weekly Monthly Other

Does your company have a written Safety & Health Program? *

Yes No

Does your company have a written Pandemic Program adherent to local, state, and/or federal requirements? *

Yes No

Have your company’s job-site supervisors completed a minimum of 30-hour Construction Safety Course? *

Yes No

Do your company’s job-site supervisors maintain a current First Aid/CPR Training? *

Yes No

Does your company conduct regular safety meetings? *

Yes No

Who conducts pre-project hazard analysis and creates the Site-Specific Safety Program

	Name	Title
-

How does your company communicate the Site-Specific program to employees and other Contractors on the site? *

How does your company enforce compliance to the Site-Specific Safety Program? *

Please provide data for the previous three (3) calendar years *

	Last Year	Two Years Ago	Three Years Ago
Year
# of OHSA Recordable Injury Cases
OSHA Recordable Incident Rate
# of Lost Time Accidents / Illnesses
Total Missed Workdays due to injury
Total Employees Hours Worked
Number of Fatalities

Please list number of OSHA Non-Compliance Citations received in the previous three (3) years *

	Last Year	Two Years Ago	Three years Ago
Year
# of Serious Citations
# of Repeat Citations
# of Willful Citations

Please upload a blanket COI for our records *

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Is your company capable of providing a payment and performance bond equal to 100% of the contract amount? *

Yes No

Has your company had any performance or payment bond claims in the past 5 years? *

Yes No

Do you have any previous disputes or Claims with Owners on bonded projects? *

Yes No

Has your company ever had a bond request denied or granted with conditions considered unacceptable? *

Yes No

Has your company ever had a bond credit terminated? *

Yes No

Date of last Bond

Date

Relevant Information Dropbox

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Has your business license been revoked at any time in the past five (5) years? *

Yes No

Have any of the owners, officers, or major stockholders of your company ever been indicted or convicted of any felony or other criminal conduct? *

Yes No

Are there any pending claims, litigation, administrative or criminal actions, arbitration, or other dispute resolution proceedings by or against your company and/or officers? *

Yes No

Has a Project Owner, General Contractor, Construction Manager, other subcontractor, or Architect filed a claim in court, arbitration, or any other legal dispute resolution or administrative forum within the past five (5) years, including any current actions, against your company? *

Yes No

Within the past five (5) years, has your company filed a claim in court, arbitration, or any other legal dispute resolution or administrative forum, including any current actions, against a Project Owner, General Contractor, Construction Manager, other subcontractor, or Architect? *

Yes No

In addition to any other form of legal action previously filed by or against your company, does your company have any current lien claims in the form of a mechanics lien or materialmen's lien against any Project Owner, Surety, Lender, General Contractor, or Construction Manager? *

Yes No

Has your company or any of its principals ever petitioned for bankruptcy, failed in business, defaulted, or been terminated on a contract awarded to you? *

Yes No

Are there any actions, legal or otherwise, by or against your company, or any other elements of your company, which would disqualify you from bidding or performing work on a public project? *

Yes No

Has your company received any citation(s) for, notice(s) of, or otherwise been alleged to have committed any labor law violations? *

Yes No

Has your company received any citation(s) for, notice(s) of, or otherwise been alleged or asserted to have committed any affirmative action violations? *

Yes No

Has your company received any citation(s) for, notice(s) of, or otherwise been alleged or asserted to have breached or violated any prevailing wage requirements? *

Yes No

Has your company been required to accept payment in the form of a joint party check to you and any third party? *

Yes No

Has your company been assessed liquidated damages or actual damages for untimely performance of your work on a project by any party able to impose such discipline? *

Yes No

Has your company ever failed to complete a project? *

Yes No

Does your company have any uncollected judgments against it? *

Yes No

Has your company or any owners, officers, or major stockholders ever been suspended, debarred or otherwise precluded from pursuing public work or ever been found to be non-responsive by a public agency? *

Yes No

Are there any other issues not addressed in the above questions which are relevant and should be addressed in evaluation of your company's qualifications for either public or private projects?

*

	Company	Telephone	Contact Person	Title	Email
Reference #1
Reference #2
Reference #3

I understand and agree that the information requested herein is subject to change, and that I am expected to supplement any information provided herein in the event of any change. I further understand that nothing in the Pre-Qualification Form represents a guarantee or promise of an award of any present or future projects to your company by Dale Corp, but it is intended to serve as a resource to Dale Corp in evaluating my company's potential fit on any such project.

As an officer of the company, I certify that the information in this Pre-Qualification Form is correct and complete as of the date of the submission of the Pre-Qualification Form. I further certify that I have reviewed all documents provided, including the Master Subcontract Agreement and Insurance Requirements.

Signature *

Clear

Name *

First Name Last Name

Date *

Date

SECTION 1: GENERAL INFORMATION

SECTION 2: PROJECT EXPERIENCE

SECTION 3: BIDDING INFORMATION

SECTION 4: SAFETY PROGRAM

SECTION 5: INSURANCE / BONDING

SECTION 6: LEGAL

SECTION 7: REFERENCES