Vendor Prequalification Form

Step 1 of 8

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Company Overview

How many years has the company been in business under its current name?*

List all prior names under which your company has operated

List the principals/officers of your company along with their titles*

Total Number of Full-Time Employees*

Primary Services Offered*

Is the company certified as a disadvantaged/minority/women-owned business, disabled veteran-owned business, B(A), etc.?*

Yes

If yes, please indicate the certificate/s and attach*

Certificates*

Max. file size: 50 MB.

Financial Information

Financial Statement*

Max. file size: 50 MB.

(Most Recent)

Annual Revenue (Last 3 Years)

Year*

Revenue in Dollars*

Year*

Revenue in Dollars*

Year*

Revenue in Dollars*

Total Value of Work Currently Under Contract*

Value of Work That Remains to be Completed*

Has the company, its parent, an affiliate, or other entity having common ownership or management been the subject of any bankruptcy proceeding within the last ten years?*

Yes

If yes, please explain*

Is the company currently in good standing with creditors?*

Yes

If no, please explain*

List Three (3) Supplier References

Company 1*

Contact Name*

First Last

Phone*

Email*

Company 2*

Contact Name*

First Last

Phone*

Email*

Company 3*

Contact Name*

First Last

Phone*

Email*

Bank Reference

Bank*

Contact Name*

First Last

Phone*

Email*

Safety Record

Do you have a written safety program in place?*

Yes

Do you OSHA safety certifications or equivalent (OSHA-10, OSHA-30, etc.)?*

Yes

Has your company had safety violations in the last 5 years?*

Yes

If yes, please explain*

EMR (Experience Modification Rate) (Last 3 Years)

Year*

EMR*

Year*

EMR*

Year*

EMR*

# of Work-Related Injuries (Last 3 Years)*

OSHA 300 Logs*

Max. file size: 50 MB.

Do you conduct safety-related training with your team?*

Yes

If yes, how often?*

Qualifications & Experience

List Successfully Completed Commercial Interior Construction Projects

Project Name*

Client Name*

First Last

Phone*

Email*

Scope of Work*

Contract Amount*

Duration of Project*

Project Name

Client Name

First Last

Phone

Scope of Work

Contract Amount

Duration of Project

Why do you believe your company would be a good fit to work with Pacific Builders?*

What makes your company stand out from your competitors in terms of reliability and performance?*

Insurance & Bonding

Limits of Coverage for General Liability - Each Occurrence*

Limits of Coverage for General Liability - Aggregate*

Limits of Coverage for Commercial Auto*

Limits of Coverage for Umbrella/Excess*

Limits of Coverage for Workers Compensation*

Limits of Coverage for Employer's Liability*

Certificate of Insurance*

Max. file size: 50 MB.

Does your company carry errors and omissions coverage? **

Yes

Does your company carry pollution coverage?*

Yes

Provide the Contact Information of Your Insurance Provider

Insurance Company*

Agent's Name*

First Last

Phone*

Email*

If requested, will your company be able to provide a payment and/or performance bond?*

Yes

Surety Company*

Phone*

Email*

Total Bonding Capacity

Aggregate Job Bonding Limit*

Total Currently Bonded*

Available Bonding Capacity*

Compliance & Legal

Have you ever been involved in any litigation concerning work or business practices?*

Yes

If yes, please explain*

In the last five years, has your company failed to complete a project?*

Yes

Or been terminated from a project?*

Yes

If yes to either, please explain*

Sign & Submit

Name*

First Last

Title*

Date*

Month

Day

Year

Signature*

Your Name
Your Name
Your Name

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Company Information

Company Overview

Financial Information

Annual Revenue (Last 3 Years)

List Three (3) Supplier References

Bank Reference

Safety Record

EMR (Experience Modification Rate) (Last 3 Years)

Qualifications & Experience

List Successfully Completed Commercial Interior Construction Projects

Insurance & Bonding

Provide the Contact Information of Your Insurance Provider

Total Bonding Capacity

Compliance & Legal

Sign & Submit