Subcontractor Prequalification Form

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Subcontractor Qualification Statement Please provide electronic copies of the following with this form: EMR Documentation from your Insurance Provider OSHA 300 Logs for the past 3 years

A.

General Year Est.:

Legal Name of Business: Office Mailing Address: City: Phone No:

State:

Zip Code:

EIN #

Company Website: Labor Affiliation: Minority Designations: Do you have In House Engineering Capacity (circle one):

Yes

No

Do you have In House Fabrication Capacity (circle one):

Yes

No

List all States in which your orgainization is legally qualified to do business:

List all trades that your company is interested in bidding:

Please list any contacts who should receive Invitations to Bid: Name:

Position:

PH:

Email:

Name:

Position:

PH:

Email:

Name:

Position:

PH:

Email:

Total number of employees:

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B.

Safety

Has your company received an OSHA (or state OSHA) or MSHA citation within the last five (5) years: If Yes, please explain:

Does your company have a written occupationals safety & health program:

Yes

No

Yes

No

Does your company conduct field safety audits to determine compliance w/ applicable regulations & procedures: Yes

No

Who conducts these audits: How often are safety audits conducted: Please list your company's Experience Modification Rate (EMR) for the three (3) most recent years: Policy Year

Interstate

Intrastate (If Applicable)

Please list your company's TRIR for the three most recent years: Policy Year

Interstate

Intrastate (If Applicable)

Number of Fatalities in the past 3 years: Number of OSHA Citations in the past 3 years: Explanation:

(Explain below or attach a separate sheet as necessary)

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C.

Experience

Please list three (3) of the most significant projects completed in the last five (5) years: Location

Project Name

Work & Contract Amount

Award Date

What's your company's annual volume: Please provide up to three (3) owner references: Owner Reference: (Co. Name)

(Contact)

(Phone)

(Co. Name)

(Contact)

(Phone)

(Co. Name)

(Contact)

(Phone)

Owner Reference: Owner Reference:

Please provide electronic copies of the following with this form: EMR Documentation from your Insurance Provider OSHA 300 Logs for the past 3 years

Please send completed forms to amy.hewis@theaustin.com

Thank you

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