Pre Qualification

Request for Subcontractors

Merchant Industrial Contracting is looking for

Subcontractors to work on opportunities in Arizona.
Please complete application and fax to 623 7380480 or by mail to MIC, 20600 W. Beloat Rd.,
Buckeye AZ 85326. If you have questions
concerning the Application; Contact Brian Shockey
at 623-521-5071, BShockey@micaz.us

CONTRACTOR PRE-QUALIFICATION FORM

Date:________________________________________________________________________________
Name of Firm:_____________________________________ Website Address:______________________
_________________________Address:_____________________________________________________
City:______________________ State:___________________ Zip:________________________________
Telephone:________________ Fax:_____________________ Email:______________________________
Contact Person:_____________________________ Title:______________________________________
Phone:___________________________Email:_______________________________________________
How long has your firm been in Business?___________________________________________________

Number of personnel in organization:

Administrative____________Professional_____________Office_________Shop_______Field_______
Type of work performed and specific trade(s) Offered:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Construction License Numbers associated with trades:_______________________________________
____________________________________________________________________________________
Is your firm a union shop?______________ If yes your local #_____________________
Has your firm ever been bonded? Yes___ No_______
If yes; what Bonding company:___________________________Phone:___________________________
Address:______________________________________________________________________________
Agent:________________________________________________________________________________
Bonding Capacity: Single________________ Aggregate________________________________________
Can your firm provide a bid bond, performance bond and a payment bond? Yes_________No_________
Comments:

Bank References:
Name of Bank

Address

Contact/Phone

Insurance Company Information: (General Liability, Auto and Workmans Comp)

Name of Company:_____________________________________________________________________
Address:______________________________________________________________________________
Contact Name:_________________________________ Phone#:_________________________________
Name of Company:_____________________________________________________________________
Address:______________________________________________________________________________
Contact Name:_________________________________ Phone#:_________________________________
Name of Company:_____________________________________________________________________
Address:______________________________________________________________________________
Contact Name:_________________________________ Phone#:_________________________________
Annual Contract Volume (last 3 years) (200_)_____(200_)_______(200_)_____
List a minimum of 5 trade/project references in the last five years:
Client/Project
Contact Name
Phone #
Type of Work

Dollar Value

List a minimum of 3 Supplier references:

Client/Project
Contact Name
Phone #

Dollar Value

Type of Work

Are there any judgments, claims or suits pending or outstanding against you? Yes____ No____
Have you ever failed to complete a project? Yes____ No____
Are you currently barred from bidding on public work? Yes____ No___
(If you answered Yes to any of the questions listed above; Provide details on a separate sheet of paper)

What is the largest dollar volume project you are interested in bidding? $_______________________
What is the largest dollar volume project you have ever performed? $__________________________
Has your firm been certified as a Small Business Enterprise : MBE? WBE? DBE?
If yes, by what agencies?_________________________________________________________________
Does your firm process lien Notices: Yes:____________________ No:____________________________
Does your firm have a Safety Manual: Yes:_____________ _______No:___________________________
Are your employees trained on Safety protocol? Yes:_____________ No:_________________________
List EMR (Experience Modification Rate) for the last 3 years: ________ __________

_____________

What payment terms does your firm prefer:_________________________________________________

Does your Firm accept Progress Payments as designed by Project Owner: Yes:_________ No: _________
Does your Firm accept credit cards and/or Procurement Cards: Yes:___________ No:_______________
If required by a project; are you willing to submit to a background check? Yes:____________No:_______
Does your firm utilize the E Verify system for your employees? Yes:_______________No:____________
Please attach the Following:

List of vehicles and equipment to provide services for services acknowledged (type, year model)
Copies of all certification letters or certificates
Copy of insurance certificates
Copy of Company literature or line card
Subcontractor list for trades not done in-house
List of geographic regions covered by your firm

Submitted by:____________________________________________________________________
Title:____________________________________________________________________________
Signature:___________________________________________ Date:________________________