Landscaping Subcontractor - Excel by ljt17435

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									                                                     Clayco                                                                          Vendor Qualification Form
                                                     St. Louis . Chicago . Detroit
                                                     www.claycorp.com

Please Print or Type
(Please attach complete list of additional office locations if applicable)
Company Name                                                                               Type of Company                                             Website/E-Mail Address
                                                                                               Subcontractor      Supplier        Other
Address #1 (Street Address)                                                                                                         Telephone Number          Toll Free Number


City/State/Zip                                                                                                                      Fax Number


Principal Contact                                                                                            Fed. Tax ID #          Bonding Company


Years in Business                      Previous Name of Company                                                                     Contact                   Telephone


Is company a certified disadvantaged business enterprise?                         Business Type:                                    Bonding Capacity
                              Type:         AA       WBE        MBE                      Corporation                Partnership
    Yes        No
                                            NA       Other:_____________                 Joint Venture              Individual
                                  Do you have any judgements, claims, arbitrations, suits, or liens currently against your                             (If yes, explain on a separate sheet
    Union           Non-Union                                                                                                             Yes    No
                                  organization?                                                                                                              and attach to this form)
Average Annual Volume:            Can you obtain the following insurance coverage?                      Insurance Company                                      EMR
                                      Worker's Compensation       $500,000           Yes         No
Design / Build Capabilities           General Liability          $1,000,000          Yes         No          Contact                                   Telephone
    Yes        No                     Automobile Liability       $1,000,000          Yes         No

Current Number of Employees                                                   Projects Under Evaluation                     Projects Bidding           Under Construction
                      Permanent             P/T           Temp   Contract
Office
Field Mgmt.
Field Workers
Other
Total:                                                            (Attach additional sheet if necessary)
Financial History (this year to date and past two (2) years)
Year      Gross Revenue        Gross Margin          Net Profit/(Loss)    Is Your Company Currently Working on Any Government Projects? If Yes, Describe
          $                                       % $                          Yes       No       Describe:
          $                                       % $
          $                                       % $
List the Organizations and/or Associations your Company or its Officers hold Membership




Project References (List Three Reference Projects)
Project Name                                                                               Project Location (City, State)                              Completion Date (MM,DD,YY)


Your Approximate Contract Amount                     Project General Contractor                                     General Contractor Contact         Contact Telephone #


Briefly Describe Work Performed:


Project Name                                                                               Project Location (City, State)                              Completion Date (MM,DD,YY)


Your Approximate Contract Amount                     Project General Contractor                                     General Contractor Contact         Contact Telephone #


Briefly Describe Work Performed:




                                                                                                 1
References Continued
Project Name                                                                        Project Location (City, State)                                  Completion Date (MM,DD,YY)


Your Approximate Contract Amount                 Project General Contractor                                  General Contractor Contact             Contact Telephone #


Briefly Describe Work Performed:




Sub-Subcontractor/Supplier References (List Three Supplier Accounts)
Sub-Subcontractor/Supplier Name                                                     Contact                                                         Phone Number


Sub-Subcontractor/Supplier Name                                                     Contact                                                         Phone Number


Sub-Subcontractor/Supplier Name                                                     Contact                                                         Phone Number




Bank References
Name of Bank                                                                        Contact                                                         Phone Number


Name of Bank                                                                        Contact                                                         Phone Number




PLEASE BE SURE TO COMPLETE THE SAFETY AND SCOPE PORTIONS CONTAINED ON PAGES 3 AND 4.
Additional Comments:




I hereby certify that the information submitted herewith, including any attachments is true and sufficiently complete so as not to be misleading.

__________________________________________________________________________________________________________________
Information Supplied By                                                                                Print Name


_____________________________________________________________
Title                                                        Date

        Return completed form to: Clayco Construction Company; 2199 Innerbelt Business Center Drive, St. Louis, MO 63114
                                  Attention: Peter Abromowitz

           For Clayco's Use
           Approved By:__________________________________________                   Date:________________________________




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                                                                                                               SAFETY QUESTIONNAIRE
Does your company document that appropriate employees are certified and/or adequately trained in the following areas:

Written/Documented Safety Program               Yes          No         N/A               Man Lift Training                            Yes     No   N/A
Documented Regular Meetings/Training            Yes          No         N/A               Excavation/Trenching                         Yes     No   N/A
Written Fall Protection Plan                    Yes          No         N/A               Personal Protective Equipment                Yes     No   N/A
Defined Work Rules                              Yes          No         N/A               Disciplinary Program                         Yes     No   N/A
Written Substance Abuse Police                  Yes          No         N/A               CPR/First Aid                                Yes     No   N/A
Hand Tool Safety                                Yes          No         N/A               Rigging Safety                               Yes     No   N/A
Scaffold/Ladders/Stairways                      Yes          No         N/A               Electrical Safety                            Yes     No   N/A
Safety Incentive Program                        Yes          No         N/A               Haz Comm                                     Yes     No   N/A
Injury Reporting                                Yes          No         N/A               Welding & Cutting Safety                     Yes     No   N/A
Lockout Tagout                                  Yes          No         N/A               Respiratory Protection                       Yes     No   N/A
Fire Protection/Prevention                      Yes          No         N/A               Incident Investigation Program               Yes     No   N/A

Do you have a documented orientation program for new hires?                 Yes          No

Do you have an investigation program for injuries, incidents and near misses?                  Yes        No
Do you hold site safety / tool box meetings?           Yes         No
Do you maintain inspection and maintenance certification records for operating equipment you own?                       Yes       No
Do you have a pre-qualification process for subcontractors?             Yes         No
Do you conduct project safety inspections?            Yes         No
Who conducts the inspections?                                                                                        How often?

Do you develop Site Specific Safety Plans for your projects?                  Yes         No

Have you been sited by Federal or State OSHA for serious violations in the last three years?                   Yes       No
If yes, list violations.

Do you have a full time safety director?       Yes          No
Name:                                                              Phone #:

                                               19                      19                 .. 19


No. of Hours Each Year


No. of Fatalities Each Year
(Total Columns 1 & 8)

No. of Lost Work Day Cases
(Total Columns 2 & 9)

No. of Recordable Cases
(Total Columns 6 & 13)

OSHA Recorded Injury Rate


OSHA Lost Work Day Rate

Please attach the last 3 years OSHA 200 Logs
Experience Modification Rate (EMR)
Attach a copy of the insurance agent's EMR verification letter and a current copy of your
Worker's Compensation Experience Rating Worksheet
Please attach any additional comments regarding your company's safety program:


                                                                                              Signature                                      Date



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                                                                                         SCOPES OF WORK/REGIONS
   Listed below are scopes of work that will be associated with your company's name. Please check all that apply.
        1000   GENERAL CONDITIONS                    6000   WOODS & PLASTICS                       10000 SPECIALTIES
        1201   TEMPORARY FACILITIES & SERVICES       6100   ROUGH CARPENTRY                        10161 TOILET PARTITIONS/ACCESSORIES
        1260   TESTING & INSPECTION SERVICES         6101   LUMBER & TRUSS SUPPLIERS               10350 FLAGPOLES
                                                     6201   FINISH CARPENTRY/MILLWORK              10441 SIGNAGE
        2000   SITEWORK                              6999   OTHER                                  10500 LOCKERS
        2030   DEMOLITION, SELECTIVE                                                               10521 FIRE EXTINGUISHERS & CABINETS
        2051   DEMOLITION, ABATEMENT                                                               10651 FOLDING & OPERABLE PARTITIONS
        2161   EXCAVATION SUPPORT SYSTEMS            7000   THERMAL & MOISTURE                     10999 OTHER
        2281   SOIL TREATMENT, PEST CONTROL                 PROTECTION
        2300   EARTHWORK                              7101 WATERPROOFING & DAMPROOFING             11000 EQUIPMENT
        2351   PILING & CAISSONS                      7201 INSULATION                              11161 DOCK EQUIPMENT
        2460   RETAINING WALL                         7251 FIRE PROOFING                           11400 FOOD SERVICE EQUIPMENT
        2481   LANDSCAPING                            7401 WALL & ROOF PANELS, SIDING              11451 RESIDENTIAL APPLIANCES
        2491   IRRIGATION                             7501 ROOFING                                 11600 LABORATORY EQUIPMENT
        2501   ASPHALT PAVING & MARKINGS              7601 ARCHITECTURAL SHEETMETAL                11999 OTHER
        2601   UTILITIES                              7901 CAULKING & SEALANTS
        2820   FENCING                                7999 OTHER                                   12000 FURNISHINGS
        2851   RAILROAD CONSTRUCTION                                                               12501 WINDOW TREATMENT
        2999   OTHER                                                                               12671 ENTRY MATS
                                                     8000   DOORS & WINDOWS                        12999 OTHER
               REINFORCING STEEL                      8101 DOORS & HARDWARE
        3000   CONCRETE                               8300 SPECIALTY DOORS                         13000 SPECIAL CONSTRUCTION
        3101   CONCRETE MATERIALS                     8360 OVERHEAD DOORS                          13120 PRE-ENGINEERED STRUCTURES
        3210   REINFORCING STEEL                      8501 WOOD & METAL WINDOWS                    13999 OTHER
        3250   REINFORCING, POST-TENSIONING           8600 SKYLIGHTS
        3301   CONCRETE CONSTRUCTION                  8801 GLASS & GLAZING                         14000 CONVEYING SYSTEMS
        3331   CONCRETE FLATWORK                      8999 OTHER                                   14201 ELEVATORS & ESCALATORS
        3400   PRECAST CONCRETE                                                                    14600 HOISTS & CRANES
        3501   CEMENTITIOUS DECKS & TOPPINGS         9000   FINISHES                               14999 OTHER
        3701   CONCRETE & MASONRY RESTORATION         9201 LATH & PLASTER
        3999   OTHER                                  9251 DRYWALL                                 15000 MECHANICAL
                                                      9301 CERAMIC & QUARRY TILE                   15301 FIRE PROTECTION
        4000   MASONRY                                9501 ACOUSTICS                               15401 PLUMBING
        4201   MASONRY                                9650 RESILIENT FLOORS                        15501 HVAC
        4999   OTHER                                  9681 CARPET                                  15999 OTHER
                                                      9701 SPECIALTY FLOORS
        5000   METALS                                 9901 PAINTING & WALL COVERING                16000 ELECTRICAL
        5101   STRUCTURAL & MISC STEEL                9999 OTHER                                   16000 ELECTRICAL
        5121   STEEL ERECTION                                                                      16600 SPECIAL SYSTEMS
        5200   METAL JOISTS                                                                        16999 OTHER
        5301   METAL DECK
        5999   OTHER                                                                               17000 DESIGN SERVICES
                                                                                                   17000 DESIGN SERVICES


Select the geographical regions from the listing below where your company is properly licensed, will provide quotes and work.
If only a portion of an area, please describe.
      NORTH AMERICA

      Northwest Region                              Northeast Region                                    North Central Region
      ID             OR                             CT            ME               PA                   IA             MN
      MT             SD                             DE            NH               RI                   IL             MO
      ND             WA                             KY            NJ               WV                   IN             WI
      NE             WY                             MA            NY               VA                   MI
                                                    MD            OH               VT
      South Region                                                                                      Southeast Region
      AR                NM                          Southwest Region                                    AL            NC
      CO                OK                          AZ           NV                                     FL            SC
      KS                TX                          CA           UT                                     GA            TN
      LA                                                                                                MS

      Western Canada                                Eastern Canada
      BC             AB                             OT            NS
      SK             MB                             QB            NB

      OTHER




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