Subcontractor Prequalification Form

Company Information

Company Name (*)

Street Address (*)

City (*) State (*) Zip (*)

Phone (*) Fax Email (*)

Website Type of Firm CSI Code/Trade

Incorp. State Incorp. Date Number of Employees

Officer Information

Owner/President (*) Phone (*)

Vice President Phone

Certifications/Licenses

Certifications  MBE WBE DBE Veteran Business Disabled Business

Union Affiliations Union Dues Current?  Yes No

City/State License  Yes No     License#

Revenue

Previous Year's Revenue Current Backlog

Insurance

Commercial General Liability  Yes No
Workers Compensation  Yes No
Automobile Liability  Yes No
Umbrella Liability  Yes No
EMR Rating < 1  Yes No

Bonding

Bonding Company Name

Agent Name Agent Phone

Single Job Limit Aggregate Limit

References

Largest Projects Completed Within Last 3 Years

Name of Project Company Name Phone Project Value

Brochure or Other References (.doc or .pdf file)

Disclaimer and Signature

I DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS MADE IN THIS SUBCONTRACTOR PRE-QUALIFICATION FORM ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND FURTHER, I ACKNOWLEDGE THIS FORM AND THE INFORMATION CONTAINED HEREIN IS SUBMITTED TO CREA CONSTRUCTION FOR THE PURPOSE OF QUALIFYING AS A SUBCONTRACTOR ON CURRENT OR FUTURE PROJECTS.

Signature (*) Date Signed (*)