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Date
Project Name

Company Information

Company Name
Contact Name
Type of Company
Street
Suite No.
City
State
Zip Code
Phone Number
Fax Number
Website
File
Contractor's License Number (attach copy)
Geographic Area of Interest
Work Specialty
Years Performing Work Specialty
Years in Business Under Present Name
Dollar Value of Work Under Contract
Dollar Value of Work In Place Last Year
Dollar Value of Work Presently Bonded
Total (Aggregate) Bonding Capacity
Surety Company
Single Project Bonding Capacity
Bonding Agent
Phone Number
Insurance Agent
Phone Number
Will the scope of work being applied for be performed by employees of this company, or will it be subcontracted to others?
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Total Number of Permanent Staff
Office Staff
Field Personnel
Average Work Force Over the Past Five Years
Is the Firm a Georgia State Certified M/WBE ?
Certificate No
Is Firm in Compliance with EEO Requirements ?
Approximate Value of Equipment Owned by Company
Does the Company have a Safety Program ?
What is the Company's EMR (Experience Modifier Ratio)
Does the Company Maintain an OSHA 300 Log (total hours worked, lost time, total accidents, etc.) ?
File
If YES, Provide a Copy .
Has the company or any company related to the current ownership of the company ever:
Failed to Complete a Contract ?
Been Involved in Bankruptcy or Reorganization ?
Had Pending Judgement Claims or Suits Against It ?
Been Assessed Liquidated Damages on Any Project ?

If YES to any of the preceding, submit details on a separate sheet.

Does the Company have a D&B Rating ?
If YES, Please Provide Your D&B Number

Trade References (Contact Name, Address, Phone Number)

1) Name
Address
Phone Number
2) Name
Address
Phone Number
3) Name
Address
Phone Number

List three projects with the same scope of work that you are applying for that were completed by the company (not a previous company orentity) within the past three years

1)
Contract Value
2)
Contract Value
3)
Contract Value

List three Construction Managers that your company has performed the same scope of work for which you are applying. Provide the nameof the firm, a contact, telephone number, and address.

1) Firm Name
Contact Name
Address
Phone Number
2) Firm Name
Contact Name
Address
Phone Number
3) Firm Name
Contact Name
Address
Phone Number

List two of your MOST SIGNIFICANT project currently UNDER construction which are the same in scope and contract value to the workbeing contemplated for this project.

1) Project Name
Location (City, State)
Scope of Work
Contractor
Contact
Tel.
Contract Amount
Completion
Is the work being self-performed? If no, see below.

If no, please list the subcontractor(s) performingthe work and the value of the contract

Sub
Contract Amount
2) Project Name
Location (City, State)
Scope of Work
Contractor
Contact
Tel.
Contract Amount
Completion
Is the work being self-performed? If no, see below.

If no, please list the subcontractor(s) performingthe work and the value of the contract

Sub
Contract Amount
Attach a complete resume of the proposed Project Manager and Superintendent to be utilized for this project. If the qualified bidder is successful inobtaining the contract, it is expected that these individuals will be committed to the project. AN INCOMPLETE PRE-QUALIFICATION FORM MAYEFFECT THE APPLICANT'S APPROVAL. Please submit only a completed form with all requested information.upload
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I hereby certify that the above information is true and complete to the best of my knowledge. I understand that the CM has the sole discretion basedon the information provided in this application and past experience to approve or deny a company's ability to bid on the project.

Signature (Officer of the Company)
Name (Print)
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