| Date of Today * |
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| Company Name * |
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| Contact Person |
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| Address * |
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| City * |
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| State * |
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| Zipcode * |
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| Telephone Number * |
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| Fax Number |
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| Federal ID# |
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| Division * |
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| Reply To - Email Address: * |
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| Scope of Work Performed |
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| Type of Work Preferred (Commercial, High End, Wood, Masonry, Steel, etc..) |
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| Specific Geographical Area you work in (Example: All of MS, Northern MS, Southern MS, AR, LA, TN ) |
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| Year Business Started ? * |
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| Number of Employees ? * |
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| Form of Ownership * |
Sole Propietorship
Partnership
S-Corp
C-Corp
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| Has the company or any of its owners Declared Bankruptcy in last 5 years ? * |
Yes
No
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| Is the company Bondable ? * |
Yes
No
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| If Yes, Single Project Limit $ |
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| Total Project Limit $ |
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| Have you ever failed to complete a project ? * |
Yes (Explain Details Below)
No
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| Details for Above |
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| Have you ever failed to complete a project on time? * |
Yes (Explain Details Below)
No
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| Details for Above |
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| Have you ever had a contract terminated due to performance ? * |
Yes (Explain Details Below)
No
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| Details for Above |
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| What is your current Workers' Compensation Experience Modification Rating (EMR) ? |
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| Does your firm have a written safety plan ? * |
Yes
No
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| Has your firm been cited by OSHA for any Serious or Willful safety violations in the last 5 years ? * |
Yes (Explain Details Below)
No
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| Details for Above |
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| Number of jobs ran at a time ? * |
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| Annual Volume for Jobs $ * |
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| Largest Job $ * |
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| Average Job $ * |
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| Smallest Job $ * |
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| Current Contract Backlog ? * |
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| Do you have a service department ? * |
Yes
No
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| Do you have 24 hour coverage ? * |
Yes
No
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| State 5 References ( Owners, Architects, and at least 2 General Contractors for work completed within the last 2 years ) |
| REFERENCE 1 |
| Contact |
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| Company |
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| Address |
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| Telephone |
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| Fax Number |
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| Your Contract $ |
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| REFERENCE 2 |
| Contact |
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| Company |
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| Address |
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| Telephone |
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| Fax Number |
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| Your Contract $ |
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| REFERENCE 3 |
| Contact |
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| Company |
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| Address |
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| Telephone |
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| Fax Number |
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| Your Contract $ |
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| REFERENCE 4 |
| Contact |
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| Company |
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| Address |
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| Telephone |
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| Fax Number |
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| Your Contract $ |
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| REFERENCE 5 |
| Contact |
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| Company |
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| Address |
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| Telephone |
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| Fax Number |
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| Your Contract $ |
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| State 3 Vendor References |
| REFERENCE 1 |
| Contact |
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| Company |
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| Address |
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| Telephone |
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| Fax Number |
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| Ave. Mo. Purchase $ |
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| REFERENCE 2 |
| Contact |
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| Company |
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| Address |
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| Telephone |
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| Fax Number |
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| Ave. Mo. Purchase $ |
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| REFERENCE 3 |
| Contact |
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| Company |
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| Address |
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| Telephone |
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| Fax Number |
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| Ave. Mo. Purchase $ |
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NOTE: Kenneth R. Thompson, Jr., Builder, Inc. requires all subcontractors to have our company listed as additional insured in regards to General Liability and Auto Liability
(Notation must be on the certificate of insurance).
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| If mailing this form, please mail to : |
Kenneth R. Thompson, Jr., Builder, Inc.
PO Box 1609 Greenwood, MS 38935-1609
Physical Address: 3204 Baldwin Road - Greenwood, MS 38930
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NO SUBCONTRACTOR WILL BE PRE-QUALIFIED WITHOUT AN INSURANCE CERTIFICATE ON FILE.
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| Please type the code shown in the image: * |
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