subcontractors

Competent | Committed | Consistent

In an effort to better understand your company’s qualifications to perform work for Ducere
Construction Services, we request that all subcontractors and suppliers complete the form below.

Date

Project Name

Company Information

Company Name

Type of Company

Corporation

Partnership

Sole Proprietorship

Contact Name

Street

Suite No

City

State

Zip Code

Phone No

Website

Fax Number

Email*

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 Presently Bonded

Surety Company

Bonding Agent

Insurance Agent

Dollar Value of Work In Place Last Year

Total (Aggregate) Bonding Capacity

Single Project Bonding Capacity

Phone Number

Will the scope of work being applied for be performed by employees of this company, or will it be subcontracted to others?

Work to be self-perfomed

Work to be subcontracted to others

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 ?

Yes

Is Firm in Compliance with EEO Requirements ?

Yes

Certificate No

Approximate Value of Equipment Owned by Company

Does the Company have a Safety Program ?

Yes

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.) ?

Yes

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 ?

Yes

Had Pending Judgement Claims or Suits Against It ?

Yes

Been Involved in Bankruptcy or Reorganization ?

Yes

Been Assessed Liquidated Damages on Any Project ?

Yes

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

Does the Company have a D&B Rating ?

Yes

If YES, Please Provide Your D&B Number

Trade References (Contact Name, Address, Phone Number)

1) Name

2) Name

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

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

Address

Contact Name

Phone Number

2) Firm Name

Address

Contact Name

Phone Number

3) Firm Name

Address

Contact Name

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.

Yes

Sub

Contract Amount

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

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.

Yes

Sub

Contract Amount

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

Upload

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)

This field should be left blank

Date

Project Name

Company Information

Company Name

Contact Name

Type of Company

Corporation

Partnership

Sole Proprietorship

Street

Suite No

City

State

Zip Code

Phone No

Website

Fax Number

Email*

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?

Work to be self-perfomed

Work to be subcontracted to others

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 ?

Yes

Is Firm in Compliance with EEO Requirements ?

Yes

Certificate No

Approximate Value of Equipment Owned by Company

Does the Company have a Safety Program ?

Yes

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.) ?

Yes

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 ?

Yes

Had Pending Judgement Claims or Suits Against It ?

Yes

Been Involved in Bankruptcy or Reorganization ?

Yes

Been Assessed Liquidated Damages on Any Project ?

Yes

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

Does the Company have a D&B Rating ?

Yes

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

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

Address

Contact Name

Phone Number

2) Firm Name

Address

Contact Name

Phone Number

3) Firm Name

Address

Contact Name

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.

Yes

Sub

Contract Amount

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

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.

Yes

Sub

Contract Amount

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

Upload

Signature (Officer of the Company)

Name (Print)

This field should be left blank