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					Subcontractor Prequalification Questionnaire
General Information:
Name of Business:
Primary Address:
Owner Contact Name:                                                                    Contact Title:
          Phone Number:                                                                Fax Number:
          Email Address:                                                               Website Address:
Estimating Contact Name:                                                               Contact Title:
          Phone Number:                                                                Fax Number:
          Email Address:                                                               Website Address:
Safety Contact Name:                                                                   Contact Title:
          Phone Number:                                                                Fax Number:
          Email Address:                                                               Website Address:
Description of Company:
Trade Description:
Applicable SIC Codes:
          Are you listed in Dun & Bradstreet?            Yes                   If yes, what is your rating?
                                                         No

          Tax ID Number:                                                             Union, Merit, or Both?



Organization Information:
Business Type:                                                                         Date Founded:
State of Formation:                                                                    Other names used:
Key Officer Name:                                                                      Contact Title:
          Years in Position:                                                           Email Address:
Principal Name:                                                                        Contact Title:
          Years in Position:                                                           Email Address:
Firm owned or controlled by parent company or other organization?                                             Describe:
Has the firm ever worked on Federal Government projects?
          Describe:
                                                                                                    Yes       No
          Is the firm registered in the Central Contractor Registration (CCR)?
                                                      SBA             SDB      DBE         MBE          WEB    Other:
          Check all that apply to the firm:
                                                      Veteran Owned            Native-American Owned




Licensing Information:
Please list all trade and professional licenses, if any, required to perform your services.
Type of license:                                                                       License Number:
Name on License:                                                                       License State:
Type of license:                                                                       License Number:
Name on License:                                                                       License State:
Type of license:                                                                       License Number:
Name on License:                                                                       License State:
Has the firm ever had a license revoked or been denied a license?
          Describe:
Has a complaint ever been filed with a Contractor's State License Board against the firm?
          Describe:



Work Experience:
Please attach a list of the major projects your firm has completed in the last three (3) years. Specify project name, location, owner,
architect/engineer, general contractor, contract amount, completion date, contact person, and phone number.

What is your average job size?                                                         Largest Job Completed:
Duration of Largest Job Completed:                                                     Job State:
Backlog as of Today:                                                                   Last Financial Statement:
12 Month Ago:
Subcontractor Prequalification Questionnaire
Dependability and Reliability Questions:
Please answer all of the questions below. Please attach a detailed explanation for any items answered "yes".

                                                                                                                           Yes         No
            1. Has                                                                        ever failed to complete

            any work awarded or has been terminated from any contract during the past ten (10) years?
            2. Does                                                                   have any pending
            judgments, claims, arbitration, pending suits, liens, or outstanding suits?
            3. Has                                                                    ever filed law suits or
            requested arbitration regarding construction contracts in the past ten (10) years?
            4. Has                                                                    or the owner(s) of the firm
            ever filed bankruptcy or engaged in voluntary or involuntary reorganization?
            5. Has your surety ever finished one of your projects?
            6. Has                                                                    ever been suspended or
            debarred from work with any government entity?
            7. Has                                                                    ever been subject to any
            false claims of acts which resulted in investigation?



Financial Information:

Please attach the firm's most recent financial statement (audited if available) for the entity that will be signing the subcontract.

                  This year's estimated annual sales volume:                                  Annual sales volume 2010:
                                  Annual sales volume 2009:                                   Annual sales volume 2008:
                 From financial statement - Working Capital:                                                  Net Worth:
          Current ratio - current assets divided by liabilities:
         Leverage ratio-total liabilities divided by net worth:
Please attach a list of major projects your firm currently has in progress (including projects awarded but not started), indicating the
project name, location, owner, architect/engineer, general contractor, contract amount, percent complete, scheduled completion date,
contact person, and phone number.



References:
Banking Reference:
Bonding Company:
Agent:
                       Length of current Surety relationship:                               Total program Bonding Limit:
                               Bonding capacity - single limit:                                            Date of bond:
                                          Largest bond issued                                                  Premium:
                                  Most recent bond amount:

Please attach a letter from your bonding company, signed by an attorney in fact, verifying the Surety name, length of relationship and
aggregate limits reflected above.


Financial Information:

Please attach the firm's most recent financial statement (audited if available) for the entity that will be signing the subcontract.

                  This year's estimated annual sales volume:                                  Annual sales volume 2010:
                                  Annual sales volume 2009:                                   Annual sales volume 2008:
                 From financial statement - Working Capital:                                                  Net Worth:
          Current ratio - current assets divided by liabilities:
         Leverage ratio-total liabilities divided by net worth:
Please attach a list of major projects your firm currently has in progress (including projects awarded but not started), indicating the
project name, location, owner, architect/engineer, general contractor, contract amount, percent complete, scheduled completion date,
contact person, and phone number.



Vendor Product and Services Registry
                                                                   Check All Applicable
            Description of Product/Service Vendor Provides                                   Preferred Manufacturer(s) Provided by Vendor
                                                                         Boxes
            Copper Pipe
            Copper Fittings
            Carbon Steel Weld Pipe
            Carbon Steel Weld Fittings
Subcontractor Prequalification Questionnaire
          No Hub Cast Iron Pipe and Fittings
          PVC - Schedule 40 Pipe and Fittings
          PVC - DWV Pipe and Fittings
          Valves Butterfly - 24"-48" High Performance
          Valves Butterfly - 2 1/2"-20" 150# Lug Style
          Valves - Ball, Gate, Check, Globe, etc.
          Valves - Balance Valves
          Valves - Pressure Reducing Valves
          Pipe Hangers - Clevis and Roller Hangers
          HVAC - Sheet Metal Products
          Drains, Carriers and Clean Outs
          Flex Connectors - Flanged, Threaded, Copper
          Plumbing Fixtures
          Unit-strut and Strut Accessories
          Rental Equipment - Aerial Equipment
          Rental Equipment - Earthwork Equipment
          Crane Rental and Rigging
          Hardware/Fasteners
          Tools - Power and Hand Tools
          Fire Stop Products
          Access Doors - Wall and Ceiling Mount
          Plumbing Equipment
          Hydronic Equipment
          HVAC Equipment
          Water Treatment Products
          Other: Describe
          Other: Describe



Subcontractor Product and Services Registry
          Description of Product/Service Vendor Provides Check All Applicable
                                                                                     Preferred Manufacturer(s) Provided by Vendor
                       (Subcontractor Only)                    Boxes
          Plumbing Installation
          Fire Stop Installation
          Sheet Metal Fabrication
          Sheet Metal Installation
          Insulation Installation
          Water Treatment Installation
          Hydronic Piping Installation
          Refrigeration Piping Installation
          Other: Describe




General Safety Questions:

Please answer all of the questions below. Please provide copies of programs, audits, orientation, etc. for any items answered "yes".
                                                                                                                        Yes        No
          1. Do you have a written Safety and Health Program?
          2. Do you conduct written audits of your Safety and health program?
          3. Do you conduct site specific safety and health plans?
          4. Do you conduct weekly safety and health audits on your site(s)?
          5. Do you have a drug and alcohol screening program?
          6. Do you have a safety orientation for new hires?
          7. Do you have a Hazard Communication program?
          8. Do you hold weekly "Tool Box Talks" safety meetings on all site(s)?
Subcontractor Prequalification Questionnaire
OSHA Logs:

Please complete the chart below using your OSHA 300 logs and provide additional required information below from the last three years.
Instructions for completion:
          1. Input your EMR rate from your insurance carrier by year, for the last three (3) years
          2. Input the number of OSHA Recordable Cases by year, for the last three (3) years
          3. Input the number of "Lost Workday" Cases by year, for the last three (3) years. Instructions for completion:
                      a. Count the number of line entries on your OSHA 300 form that received a check mark in column (H) or refers to
                      the entry for column (H) on the OSHA 300A form
          4. Calculate your TRIR by year, for the last three (3) years. Instructions for completion:
                      a. Count the number of line entries on your OSHA 300 form or refer to the OSHA 300A form and sum the entries
                      for columns (G), (H), (I), and (J).
                     b. Use the formula: Total number of injuries and illnesses X 200,000 ÷ Number of hours worked by all employees =
                     Total recordable incident rate
                                 Incident Rate =          (#recordable injuries)*(200,000)
                                                                    Work Hours of Exposure
         5. Input the number of fatalities by year, for the last three(3) years. Instructions for completion: Refer to the number found on
         the OSHA 300 form in column (G)

                                 Total OSHA Recordable                             Total Recordable
             Year       EMR                            Lost Workday Cases                               Fatalities
                                         Cases                                       Incident Rate




         1. Provide a copy of your EMR for the last three (3) years on letter head from your insurance carrier.
         2. Provide a copy of your OSHA 300 logs for the last three (3) years
Subcontractor Prequalification Questionnaire
Corporate Safety History Questions:
Please answer all of the questions below. Please provide copies of programs, audits, orientation, corrective actions, etc. for any items
answered "yes".
                                                                                                                         Yes          No
          1.Has your company had any OSHA citations in the past three (3) years?
          2. Do you supply your employees with the Personal Protective Equipment (PPE)?
          3. Do you train your employees and keep training records for Lockout/Tag out?
          4. Do you train your employees and keep training records for Forklift Operations?
          5. Do you train your employees and keep training records for Aerial/Scissor Lift?
          6. Do you train your employees and keep training records for Respirators?

            7. Do you train your employees and keep training records for Competent Rigger/Signal Person?
            8. Do you train your employees and keep training records for Hot Work
            9. Do you train your employees and keep training records for Scaffold Work?
            10. Do you train your employees and keep training records for Asbestos (min 2 hours)?
            11. Do you train your employees and keep training records for First Aid/CPR?
            12. Do you train your employees and keep training records for AED?
            13. Do you train your employees and keep training records for Blood borne Pathogens?
            14. Do you train your employees and keep training records for OSHA 10?
            15. Do you train your employees and keep training records for OSHA 30?
            16. Do you train your employees and keep training records for PSM?
            17. Do you train your employees and keep training records for Industrial Hygiene?
            18. Do you train your employees and keep training records for Organizational Health?
            19. Do you train your employees and keep training records for Emergency Evacuation?
            20. Do you have any additional safety or health training for your employees?



Safety and Health Protection and Prevention Questions:
Please answer all of the questions below. Please provide copies of programs, audits, orientation, corrective actions, etc. for any items
answered "yes".
                                                                                                                         Yes          No
            1. Do you have a written disciplinary policy for safety and health violations which address
            both employees and subcontractors?
            2. Do you company utilize pre-task planning cards for daily work?
            3. Do you have a Job Hazard Analysis (JHA) process in place for each site?
            4. Do you have a designated safety contact person for each site?
            5. Do you have an MSDS process in place for each site?



Please attach any additional information that you feel will help us determine your firm's qualifications and expertise, including owner or
general contractor references, etc.


Statement of Compliance and Authorization to Release Information:


By submitting this application, whether electronically, on-line, or hard copy form, I certify that the facts contained herein are
true and complete to the best of my knowledge and belief. I understand that, if given the opportunity to propose on a
project or if awarded a subcontract, false statements on this application shall be grounds for disqualification or subcontract
termination. I understand that the information provided herein may be verified by RKMI. I hereby release RKMI and its
affiliated corporation and others from liability or damage that may result from furnishing the information requested.


Signature                                                    Title                                                   Date

				
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posted:4/5/2012
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