SUBCONTRACTOR PRE-QUALIFICATION FORM

All subcontractors are required to complete this questionnaire. The contents of this questionnaire will be considered and used solely to determine your firm’s qualification to perform work for Rudy L. Hawkins Electrical Contractor, Inc.

Return completed form to: HE@RudyLHawkinselectrical.com

PLEASE NOTE: This form must be filled out completely. Missing information may result in disqualification of consideration.

Application Date

Date

Company Name

Type of Company

Type of Work Performed

Street Address

City/State/Zip

Principal Contact

Phone Number

Area CodePhone Number

Email Address

example@example.com

Year Business was Established

States We Do Work In

Union/Non-Union

UnionNon-Union

Previous Name of Company (if applicable)

Contractor’s License #

D&B #

Qualified Minority Business?

MBEWBEDBE

List your Company's # of Injuries/Illnesses from your OSHA 300 Logs

	Last Year	1st Prior Year	2nd Prior Year
Experience Modification Rate EMR
Total # of Fatalities. (From Column G on the OSHA 300 Log)
Total # of OSHA Recordable Incidents. (Total of Columns H, I, and J on the OSHA 300 Log)
Total # of Lost Work Day Incidents. (Column H on the OSHA 300 Log)
Total # of other recordable cases. (Column J on the OSHA 300 Log)
Total # of Annual Man-Hours Worked.

Please check if your Company implements the following safety controls:

Has a written safety program.

YesNo

Has an Implemented Drug Screening Policy for all Employees.

YesNo

Performs Safety Orientation & Training for all Employees.

YesNo

Performs Continuing Safety Education for all Employees.

YesNo

Safety/Health Professional Contact:

Name

Title

Phone Number

Area CodePhone Number

Email Address

example@example.com

Provide summary of three largest projects presently under construction:

Project 1

Project 2

Project 3

Please provide the following bonding information:

Can you provide a Performance Bond?

Bond Rating

Bonding Capacity

Single Project

Aggregate

Bond Cost (% or $/1000)

Name of Bonding Company

Contact

Phone Number

Area CodePhone Number

Last Type of Bond Issued

Date

Amount ($)

Provide three client references:

Company Name

Contact

Phone Number

Area CodePhone Number

Company Name

Contact

Phone Number

Area CodePhone Number

Company Name

Contact

Phone Number

Area CodePhone Number

Provide financial references:

Name of Bank

Contact

Phone Number

Area CodePhone Number

Name of Bank

Contact

Phone Number

Area CodePhone Number

Provide three supplier references:

Company Name

Contact

Phone Number

Area CodePhone Number

Company Name

Contact

Phone Number

Area CodePhone Number

Company Name

Contact

Phone Number

Area CodePhone Number

I hereby certify that the information submitted herein, including any attachments is true and sufficiently complete so as not to be misleading.

Completed by

(Signature)

Title

Date Completed

Date

Note: Submit this form along with a copy of your Standard Certificate of Insurance

Certificate of Insurance File Upload

Financial Review

Date

Safety/Insurance Review

Date

SQF Complete?:

YesNo

SUBCONTRACTOR PRE-QUALIFICATION FORM

Background

Safety

Schedule

References

For Office Use Only