SCDP Contractor Application

Contractor Application Form

for Small Cities Development Program
Application Information
Name of Firm*
Firm Owner(s)*
Contractor License Number:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Calling Hours*
Email*
example@example.com
Name of Person Completing Bids*
Are you a General Contractor handling all phases of work?*

YesNo
When was your firm established?*
Are you debarred per the Excluded Parties List at www.sam.gov?*

YesNo
Are you an elected official (Council Member, Mayor, etc.)?*

YesNo
If yes, you may have a conflict of interest where an exception may or may not be available.
Are you currently listed as a lead supervisor?*

YesNo
Please submit a copy of certificate
Are you currently certified as an EPA lead renovator?*

YesNo
Please submit a copy of certificate
What is your Unique Entity ID#?*
per www.sam..gov
Are your workers trained on lead safe work practices?*

YesNo
Are you a woman-owned or minority-owned business?*

YesNo
Are you a Section 3* contractor?*

YesNo
*A Section 3 business is defined as either: 1. At least 51% owned and controlled by a low or very low income person OR 2. Over 75% of labor hours performed for the business over the prior 3-month period were performed by Section 3 workers.
In which towns and areas would you be willing to work?*
Can you handle more than one $5,000 job at a time?*

YesNo
Do you guarantee your work for one year?*

YesNo
Insurance
Contractors must submit evidence of licenses that are required by the State of Minnesota. Our program also requires contractors to carry the following insurance coverage: (Submit proof of insurance and current Minnesota License at the end of this form, to kristi@nwmnhra.org, or mail to: NW MN Multi-County HRA Attn: Kristi, PO Box 128, Mentor, MN 56736
- Comprehensive General Liability Insurance
  - Bodily Injury $300,000 each person; $300,000 each occurrence
  - Property Damage $100,000 each occurrence
- Comprehensive Automobile Liability
  - Bodily Injury $300,000 each person and each accident
  - Property Damage $50,000 each occurence
Do you carry the above insurance coverage?*

YesNo
Do you carry Workers' Compensation Insurance?*

YesNo
Qualifications & Experience

Indicate the type of work you are qualified to do and the years of experience.
General Carpentry*

YesNo
Years of Experience*
Roofing*

YesNo
Years of Experience*
Structural Support Repair*

YesNo
Years of Experience*
Window Replacement*

YesNo
Years of Experience*
Door Replacement*

YesNo
Years of Experience*
Siding*

YesNo
Years of Experience*
Concrete Repair*

YesNo
Years of Experience*
Plumbing*

YesNo
Years of Experience*
Lead Hazard Reduction*

YesNo
Years of Experience*
Foundation Repair*

YesNo
Years of Experience*
Attic & Sidewall Insulation*

YesNo
Years of Experience*
Chimney Repair*

YesNo
Years of Experience*
Heating & Ventilation*

YesNo
Years of Experience*
Electrical*

YesNo
Years of Experience*
Recent Work

Please list three most recent jobs, type of work, and contact person and phone number
Job #1
Job & Type of Work*
Contact*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Job #2
Job & Type of Work*
Contact*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Job #3
Job & Type of Work*
Contact*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
My signature below authorizes the Small Cities Development Program (SCDP) administrator to verify the above information. I certify that the above information is true and complete to the best of my knowledge.
Company Name*
Date*

MonthDayYear
Date
Signature*
Document Upload
Proof of Minnesota License

Cancelof
Proof of Insurance

Cancelof
Lead Supervisor Certificate

Cancelof
EPA Lead Renovator Certificate

Cancelof
Should be Empty:

Contractor Application Form

Application Information

Insurance

Qualifications & Experience

Recent Work

Job #1

Job #2

Job #3

Document Upload