Subcontractor Registration
Please provide all required information to register your business with Danella Companies, Inc.
Company Information
Business Name
*
As written on W-9
Company DBA and Any Subsidiaries
CEO/Majority Owner Name
*
First Name
Last Name
Corporate Officers/Members (Names, Titles, and Emails)
Number of Full Time Employees
*
Business Started
*
-
Month
-
Day
Year
Date
Federal Tax ID or Social Security Number
*
State of Incorporation
*
DUNS #
Federal DOT Number
Website
www.COMPANY.com
Type of Organization
*
Sole Proprietorship
Joint Venture
Partnership
Corporation
Other
Please upload a copy of your Form W-9
*
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Does your business qualify as one of the following?:
Small Business
Minority Owned Business
Woman Owned Business
Veteran Owned Business
Service Disabled Veteran Owned Business
Small Disadvantaged Business
If certified, which certifying agency?
National Minority Supplier Development Council (NMSDC)
Women's Business Enterprise National Council (WBENC)
Other
If certified, please upload the certification
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Headquarters Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (If Different than above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Subcontractor Representations
If for any reason a representation on this questionnaire is not accurate and complete as of the time the subcontractor signs this form, the subcontractor must identify the provision and explain the reason in detail on a separate sheet. Absent such an explanation, the Subcontractor represents that the following statements throughout this entire application are complete and accurate. The following questions apply to (i) Subcontractor, Subcontractor’s parent, subsidiaries, and affiliates (if any); (ii) any joint venture (including its individual members) and any other form of partnership (including its individual members) which includes Subcontractor or Subcontractor’s parent, subsidiaries, or affiliates; (iii) Subcontractor’s directors, officers, principals, managerial employees, and any person or entity with a 10% or more interest in Subcontractor; (iv) any legal entity, controlled, or 10% or more of which is owned, by Subcontractor, or by any director, officer, principal, managerial employee of Subcontractor, or by any person or entity with a 10% or more interest in Subcontractor. (If the answer to any question is “YES,” Subcontractor must provide all relevant information on a separate sheet)
Within the past five (5) years, has Subcontractor been declared not responsible to receive a public or private contract?
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Yes
No
Has Subcontractor been debarred, suspended, or otherwise disqualified from bidding, proposing, or contracting?
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Yes
No
Is there a proceeding pending relating to Subcontractor’s responsibility, debarment, suspension, or qualification to receive a public or private contract?
*
Yes
No
Within the past five (5) years, has Subcontractor defaulted on a contract or been terminated for cause on a public or private contract?
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Yes
No
Has a public or private entity requested or required enforcement of any of its rights under a surety agreement on the basis of Subcontractor’s default or in lieu of declaring Subcontractor in default?
*
Yes
No
Within the past five (5) years, has the Subcontractor been required to engage the services of an Integrity Monitor in connection with the award of or in order to complete any public or private contract?
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Yes
No
Within the past (5) years, have Subcontractor’s safety practices/procedures been evaluated and ruled as less than satisfactory by a public or private entity?
*
Yes
No
Has Subcontractor’s Workers’ Compensation Experience Rating (also known as the Experience Modification Rate or EMR) been 1.2 or greater at any time in the last five (5) years? If yes, please explain.
*
Yes
No
Within the past five (5) years, has the Subcontractor been accused of violating equal opportunity or nondiscrimination laws?
*
Yes
No
Within the past five (5) years, has the Subcontractor been accused of violating prevailing wage laws, regulations, or executive orders?
*
Yes
No
Upload Explanation to any "YES" Answers above
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Subcontractor Representations (continued)
To the best of your knowledge after diligent inquiry, in connection with the business of Subcontractor or any other firm which is related to Subcontractor by any degree of common ownership, control, or otherwise, do any of the following statements apply to: (i) Subcontractor, Subcontractor’s parent, subsidiaries, and affiliates (if any); (ii) any joint venture (including its individual members) and any other form of partnership (including its individual members) which includes Subcontractor or Subcontractor’s parent, subsidiaries, or affiliates; (iii) Subcontractor’s directors, officers, principals, managerial employees, and any person or entity with a 10% or more interest in Subcontractor; (iv) any legal entity, controlled, or 10% or more of which is owned, by Subcontractor, or by any director, officer, principal, managerial employee of Subcontractor, or by any person or entity with a 10% or more interest in Subcontractor? (If the answer to any question is “YES,” Subcontractor must provide all relevant information on a separate sheet)
Within the past ten (10) years has been convicted of or pleaded nolo contendere to (i) any felony or (ii) a misdemeanor related to truthfulness in connection with business conduct.
*
Yes
No
Is currently disqualified from selling or submitting bids/proposals to or receiving awards from or entering into any contract with any federal, state, or local government agency, any public authority or any other public entity.
*
Yes
No
Has within a ten (10) year period preceding the date of this Questionnaire been convicted of or had a civil judgment rendered against it for or in relation to: (i) commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local)transaction or contract under a public transaction; (ii) collusion with another person or entity in connection with the submission of bids/proposals; (iii) violation of federal or state antitrust statutes or False Claims Acts; or (iv) commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property.
*
Yes
No
In the past ten (10) years, has Subcontractor entered into a consent decree, deferred prosecution agreement or a non-prosecution agreement?
*
Yes
No
In the past seven (7) years, have any bankruptcy proceedings been initiated by or against the Subcontractor (whether or not closed) or is any bankruptcy proceeding pending by or against the Subcontractor regardless of the date of filing?
*
Yes
No
In the past five (5) years, have there been any judgments or tax liens of $100,000 or more, including but not limited to judgments based on taxes owed, fines and penalties assessed by a government agency against Subcontractor at any time?
*
Yes
No
During the past five (5) years, has the Subcontractor failed to file any applicable federal, state, or local tax return?
*
Yes
No
Upload Explanation to any "YES" Answers above
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Financial History
Three Year Business Revenue
Bonding Capacity
Enter a Dollar Value
Upload Most Recent Financial Statement
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Insurance Information
Insurance Broker/Producer Name
*
Insurance Broker/Producer Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Broker/Producer Contact Information
*
First Name
Last Name
*
example@example.com
*
Please enter a valid phone number.
Format: (000) 000-0000.
Upload Certificate of Insurance
*
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Certificate Holder/Additional Insured fields do not need to be completed at this time
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Safety Information
Please List Your Three Year Experience Modification Rating (EMR) (Enter 0 if Not Applicable)
*
Provide EMR Letter for the past three years
*
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Please List Your Three Year DOT Violations (Enter 0 if Not Applicable)
*
Please List any OSHA Violations in the last 3 years (Enter 0 if Not Applicable)
*
Provide Copies of your OSHA Logs for the Past Three Years
*
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Explain how safety and quality is managed/enforced within your company
*
Please type "see attached" if you will be providing an attachment
Do you have a written safety and quality program? If so, please upload at the bottom of this sheet
*
Yes
No
Do you conduct criminal history checks?
*
Yes
No
Do you employ anyone, or hire individuals, whose criminal background check revealed felony or misdemeanor convictions within the last ten (10) years?
*
Yes
No
Do you check your employees against the National/State Sex Offender Registry to yield a national and all-states search?
*
Yes
No
Do you verify employee’s citizenship, most recent country of permanent residence, and legal right to work in the jurisdiction inwhich the employee will be working?
*
Yes
No
Are all employees provided with formal safety training as applicable to their work and current regulations?
*
Yes
No
Do you require a new employee orientation and onboarding session for all employees?
*
Yes
No
Do you have a PPE (Personal Protective Equipment) Policy? If so, please provide a copy.
*
Yes
No
Do you have an incident reporting and investigation procedure? If so, please provide a copy
*
Yes
No
Do you have a near-miss reporting program?
*
Yes
No
Do you have a Job Safety Analysis or Task Hazard Analysis program in place? If so, please provide a copy of the form utilized by your employees
*
Yes
No
Are regular safety meetings held, and documented, on project sites? If so, list the contact information below
*
Yes
No
Do you have personnel trained in first aid and CPR on-site at each job location?
*
Yes
No
Do you maintain a substance abuse program?
*
Yes
No
Safety Lead Contact Information
*
First Name
Last Name
*
Title
*
example@example.com
*
Please enter a valid phone number.
Format: (000) 000-0000.
Safety Programs File Upload
*
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Operations Information and References
How would you describe your company?
*
Large General Contractor
Small General Contractor
Subcontractor
Supplier/Vendor
Please provide a summary of the services your company provides
*
Do you self perform all work, use subcontractors, or both?
*
Self Perform
Subcontract
Both
What is the Labor Affiliation of your workforce? Select all that apply
*
Union
Non-union
Open Shop
Prevailing Wage
Please list the states in which your company performs work
*
Do you hold licenses in any of these states? If so, which ones and what license?
Provide information on all company locations (Activity/Operation, City/State, and FTEs from each location)
*
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References and Customer History
For which companies have you performed work?
*
Reference #1
*
First Name
Last Name
*
Company Name
*
example@example.com
*
Please enter a valid phone number.
Format: (000) 000-0000.
*
Reference #2
*
First Name
Last Name
*
Company Name
*
example@example.com
*
Please enter a valid phone number.
Format: (000) 000-0000.
*
Reference #3
First Name
Last Name
Company Name
Please enter a valid phone number.
Format: (000) 000-0000.
example@example.com
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Danella Routing
Please help us get your registration information to the right team
Please select the Danella company or companies to receive your registration
*
Danella Construction Corp. of FL, Inc.
Danella Construction Corp. of PA, Inc.
Danella Construction of NY, Inc.
Danella Construction, Inc. (NC/VA)
Danella Communication Services, Inc.
Danella Engineering and Construction Corp.
Danella Line Services Company, Inc.
Danella Line Services of DE, Inc.
Danella Line Services of NY, Inc.
Danella Line Services of MA, Inc.
Danella Power Services, Inc.
Danella Rail Services Corp.
Danella Rental Systems, Inc.
Danella Storm Restoration
J. Daniel & Company, Inc.
Viking Utility Services, Inc.
Unknown
Danella Contact
*
First Name
Last Name
*
example@example.com
Certification
I hereby certify that the information provided in this document is true and accurate, to the best of my knowledge, and that I am an authorized representative of the Subcontractor (i.e. an employee or agent who is authorized to make representations for and enter into agreements that are binding on the Subcontractor):
Authorized Representative
*
First Name
Last Name
*
Title
*
Please enter a valid phone number.
Format: (000) 000-0000.
*
Email Address: example@example.com
Signature of Authorized Representative
*
Date
*
-
Month
-
Day
Year
Date
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