Hvac Financial Statement - DOC by ygw87962

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									                                                                  TO BE COMPLETED BY MARNELL
                                                                 Date
                                                                 Approved
                                                                 Not Approved
                                                                               Subcontractor
                                                                                     Vendor
                                                                                  Consultant



Contractor’s Qualification Statement

The Undersigned certifies under oath that the information provided herein is true and sufficiently
complete so as not to be misleading.

SUBMITTED BY

COMPANY:

CONTACT NAME:                                                                Corporation

ADDRESS:                                                                     Partnership

                                                                             Individual
PHONE:             -        -

FAX:           -        -                                                    Joint Venture

E-MAIL:                                                                      Other

PRINCIPAL OFFICE:

ADDRESS:


UNION:         NON-UNION:                  MBE / WBE: YES       NO                TYPE:

NAME OF PROJECT (if applicable):

TYPE OF WORK (files separate form for each Classification of Work):

    General Construction                           HVAC

    Plumbing                                       Electrical

    Other (please specify)




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If your organization is a Joint Venture, for each question in this statement, please respond to the
question both as a Joint Venture entity and individual entities.

ORGANIZATION

How many years has your organization been in business as a Contractor?


How many years has your organization been in business under its present business name?


Under what other or former names has your organization operated?

If your organization is a corporation, answer the following:
      Date of incorporation:
      State of incorporation:
      President’s name:
      Vice-president’s name(s)
      Secretary’s name:
      Treasurer’s name:

If your organization is a partnership, answer the following:
      Date of organization:
      Type of partnership (if applicable):
      Name(s) of general partner(s)

If your organization is individually owned, answer the following:
      Date of organization:
      Name of owner:

If the form of your organization is other than those listed above, describe it and name the
principals:



LICENSING
List the jurisdictions and trade categories in which your organization is legally qualified to do
business, and indicate registration or license numbers, if applicable.       (PLEASE ATTACH
COPIES)



List jurisdictions in which your organization’s partnership or trade name is filed.




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EXPERIENCE
List the categories of work that your organization normally performs with its own forces.


Claims and Suits. (If the answer to any of the questions below is yes, please attach details.)

       Has your organization ever failed to complete any work awarded to it?

       Has your organization ever been terminated from a construction project?

       Except Workers’ Compensation claims, are the any judgments, claims, arbitration
        proceedings or suits pending or outstanding against your organization or its officers?


       Has your organization filed any lawsuits or requested arbitration with regard to
        construction projects within the last five years?

       Within the last five years, has any officer or principal of your organization ever been an
        officer or principal of another organization when it failed to complete a construction
        contract? (If the answer is yes, please attach details.)

       Has your organization ever been disciplined by any authority, including any contractors’
        board, NSHA or OSHA?

On a separate sheet, list major construction projects your organization has in progress, giving
the name of project, owner, architect, contract amount, percent complete and scheduled
completion date, type or discipline of work being performed.

State total worth of work in progress and under contract: $

On a separate sheet, list the major projects your organization has completed in the past five
years, giving the name of project, owner, architect, contract amount, date of completion and
percentage of the cost of the work performed with your own forces, type or discipline of work
being performed.

State average annual amount of construction work contracted by your organization during the
past five years: $

On a separate sheet, list the construction experience and present commitments of the key
individuals of your organization.

Attach a copy of your organization’s safety plan.

Attach a copy of your organization’s QA / QC plan.

Attach a copy of your organization’s drug / alcohol testing plan.

Attach copies of any safety/OSHA citations issued to your organization.



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Attach a copy of your organization’s workers compensation EMR.

Attach a copy of your organization’s insurance TRFR.

REFERENCES

Trade References:




Bank References:




Surety:          Name of bonding company:

                 Name and address of agent:


                 Bonding Capacity          / Limit per project

Insurance:       CGL Carrier & summary of liability coverage



FINANCING

Financial Statement. Attach a financial statement, preferably audited, including your
organization’s latest balance sheet and income statement showing the following items:

         Current Assets (e.g., cash, joint venture accounts, accounts receivable, notes
          receivable, accrued income, deposits, materials inventory and prepaid expenses);
         Net Fixed Assets;
         Other Assets;
         Current Liabilities (e.g., accounts payable, notes payable, accrued expenses, provision
          for income, taxes, advances, accrued salaries and accrued payroll taxes);
         Other Liabilities (e.g., capital, capital stock, authorized and outstanding shares par
          values, earned surplus and retained earnings).

Name and address of firm preparing attached financial statement, and date thereof:


                                                                 Date:

Is the attached financial statement for the identical organization named on page one?


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If not, explain the relationship and financial responsibility of the organization whose financial
statement is provided (e.g., parent-subsidiary).

Will the organization whose financial statement is attached act as guarantor of the contract for
construction?

By signing this “Pre-Qualification Statement” Contractor, Subcontractor, Vendor and/or Supplier
grants Marnell Companies, LLC or their Agent and/or Representative permission to make the
necessary inquiries to confirm information noted within this document.

SIGNATURE

    Dated at this           day of         , 20         .

        Name of Organization:

        By:

        Title:

       , being duly sworn deposes and says that the information provided herein is true and
sufficiently complete so as not to be misleading.

        Subscribed and sworn before me this            day of     , 20

        Notary Public:

        My Commission Expires:




E-mail completed form to ttremaine@marnellcompanies.com for review and processing.



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