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Subcontractor Qualification Form
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QC Form
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1901 Project – Subcontractor Qualification Form
Project Location: Chicago, IL
1901 Project – Subcontractor Qualification Form
Company Name:
DBA (if any):
Business Address:
First Name
Middle Name
Last Name
Phone Number:
Email Address:
Interviewer
- Select -
Jerry
Charles
Shun
Johnny
Mejai
Daniel
Website:
Year Established:
Owner(s) Name(s):
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Does your business Qualify as the Below?
Minority Owned
Women Owned
Certification & Compliance
MBE
WBE
DBE
Section 3
Veteran-Owned
Other (Specify):
Certifying Agencies:
License Numbers (if applicable):
Union Affiliation:
Yes
No
If yes, list unions:
Bonding Capacity: $
Insurance Carrier:
Coverage limits:
Primary Trade
- Select -
Carpentry
Plumbing
Roofing
Excavation
Electrical
Masonry
Painting
Landscaping
HVAC
Concrete
Drywall
Flooring
Other
Other:
Additional trades
Carpentry
Electrical
HVAC
Plumbing
Masonry
Concrete
Roofing
Painting
Drywall
Excavation
Landscaping
Flooring
Other
Other:
Project Experience
Total Employees:
Field Workers:
Administrative/Office Staff:
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Can you meet certified payroll requirements
Yes
No
Willing to participate in the 1901 Workforce Initiative?
Yes
No
# of OSHA Violations in the past 3 years:
Drug-Free Workplace Policy in Place?
Yes
No
Are you currently involved in litigation?
Yes
No
Do you hire returning citizens or Section 3 residents?
Yes
No
Do you have an OSHA safety plan?
Yes
No
Experience Modification Rate (EMR):
Has your company ever failed to complete a contract?
Yes
No
Are you currently debarred from public projects
Yes
No
Required Attachments
Copy of licenses and certifications
Certificate of Insurance
OSHA 300 Logs (past 2 years)
Most recent financial statement or proof of bonding
Resumes of key personnel
Three project references
Upload your attachments
Choose File
Authorized Signature
I certify that the information provided above is true and complete to the best of my knowledge.
Name:
Signature
Sign Here
Date
Title:
Submit
Save & Resume
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