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SUBCONTRACTOR PREQUALIFICATION
(Must Be Completed For Consideration - All Information Treated Confidentially)
Company Details
*
Company Name
Street Addres
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Telephone Number
*
Fax Number
*
Tax Identification Number
*
Association
*
Non-Union
Union
President
President Email
Vice President
Vice President Email
Treasurer
Website
Years In Business
*
Type Of Business
*
Sole Proprietorship
Partnership
Corporation
State Of Incorporation
*
Date Of Incorporation
*
MM slash DD slash YYYY
Other Names Company Has Operated Under
*
Office Locations
*
Please Select Voss Lighting Branch For Whom Work Will Be Performed:
*
--
10 | Lincoln
11 | Omaha
15 | Minneapolis
17 | Kansas City
18 | St Louis
20 | Grand Rapids
30 | Oklahoma City
35 | Tulsa
40 | Dallas
42 | San Antonio
44 | Houston
50 | Albuquerque
55 | Phoenix
57 | Denver
65 | Raleigh
70 | Atlanta
Licensed In The Following States/Municipalities
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Please Provide Current State/Municipal License Numbers For Each Entry Above
*
Current 3-Year Average Size Of Field Workforce By Classification
[] Supervisor (Superintendant, General Foreman, Foreman) [] Journeymen [] Apprentice
COMPANY CONTACT INFORMATION
Name
*
Title
*
Email
*
Wireless Number
Telephone Number
*
Fax Number
AFFIRMATIVE ACTION/EEO INFORMATION
Does Your Company Have An Affirmative Action Program For Employees?
*
Yes
No
Do You Provide Sexual Harassment In The Workplace Orientation And/Or Training?
*
Yes
No
MINORITY / DISADVANTAGED BUSINESS ENTERPRISE RELATIONS / PARTICIPATION
Does Your Company Use MBE And/Or DBE Subcontractors And/Or Vendors?
*
Yes
No
Are You Certified As A Minority Or Disadvantaged Business Enterprise?
*
Yes
No
Note: Please Provide A Copy Of All Certifications
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BANK REFERENCES
Bank Information
Bank Name
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Zip
Telephone Number
Amount Of Bank Line Credit
Secured
Yes
No
INSURANCE
Name Of Insurance Company
*
How Long With Insurance Company
*
Has Your Company Ever Had Its Workman's Compensation Cancelled?
*
Yes
No
If Yes, Please Provide Reason.
*
Voss Lighting Insurance Requirements
Required: Please upload a digital copy of your Certificate of Insurance that meets or exceeds Voss Electric Company dba Voss Lighting requirements found on the following link.
*
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BONDING
Total Aggregate Bonding Capacity
Total Per Project Bonding Capacity
Name Of Bonding Company
How Long With This Bonding Company?
SAFETY
MOST CURRENT THREE YEAR HISTORY
Experience Modifier Rate (EMR)
*
2015
2016
2017
OSHA Recordable Incident Rate
*
2015
2016
2017
Lost Workday Incident Rate
*
2015
2016
2017
Number Of Lost Workdays
*
2015
2016
2017
Number Of Recordable Injury Cases
*
2015
2016
2017
Total Employee Hours Worked
*
2015
2016
2017
Number Of Fatalities
*
2015
2016
2017
Does your Company have a documented Safety Program?
*
Yes
No
If your Company has a documented Safety Program, please submit a copy of your current Safety Manual.
*
Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 2 MB.
Required: Please upload digital copies of your annual EMR rate notifications from your insurance company for the corresponding years.
*
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Accepted file types: jpg, gif, png, pdf, docx, Max. file size: 100 MB, Max. files: 10.
Required: Please upload digital copies of your annual OSHA 300A Summaries for the most recent three year period shown above.
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Has Your Company Received Any OSHA Citations In The Most Current Three Year Period?
*
Yes
No
If Yes, Please List.
Number Completing OSHA 10-Hour Or 30-Hour Courses
*
10-Hour
30-Hour
LIST THREE RECENTLY COMPLETED CONTRACTS
Project Name
*
Contract Value
*
Type Of Contract Work
*
Year Completed
*
Project Address
Street Address
City *
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State *
ZIP Code
Customer Contact Name
Customer Contact Position
Customer Contact Email
Customer Contact Telephone Number
Project Name
*
Contract Value
*
Type Of Contract Work
*
Year Completed
*
Project Address
Street Address
City *
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State *
ZIP Code
Customer Contact Name
Customer Contact Position
Customer Contact Email
Customer Contact Telephone Number
Project Name
*
Contract Value
*
Type Of Contract Work
*
Year Completed
*
Project Address
Street Address
City *
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State *
ZIP Code
Customer Contact Name
Customer Contact Position
Customer Contact Email
Customer Contact Telephone Number
Other References As Desired (Upload Information As Needed)
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Accepted file types: jpg, gif, png, pdf, docx, Max. file size: 100 MB, Max. files: 10.
THIS FORM MUST BE FULLY COMPLETED, SIGNED, AND DATED TO BE CONSIDERED. RETURN THIS DOCUMENT AND ALL REQUESTED INFORMATION AS QUICKLY AS POSSIBLE FOR REVIEW BY VOSS ELECTRIC COMPANY DBA VOSS LIGHTING.
CHECKLIST
Fully Completed Subcontractor Prequalification Shall Include The Following (Required Prior To Entering Into Any Contractual Agreement With Voss Electric Company dba Voss Lighting):
Checklist Information
Minority And/Or Disadvantaged Business Enterprise Certifications.
Copy Of Certificate Of Insurance Per Requirements Above.
Current Audited Consolidated Balance Sheet And Income Statement (Unaudited, if Not Available).
Credit Limit Verification Document.
All Information Required In Section Titled: 'SAFETY'
CERTIFICATION
The undersigned certifies that he/she is an officer of the company listed below or is authorized to sign on behalf of the company and that the information provided above is true and correct and is given to introduce your company to Voss Electric Company dba Voss Lighting for consideration as a prequalified subcontractor. The undersigned acknowledges that Voss Electric Company dba Voss Lighting is utilizing the information in this document in the determination of possible future binding legal documents with your company and all information herein shall be considered and binding conditions to any such legal documents. The undersigned represents and warrants that you will notify Voss Electric Company dba Voss Lighting of any changes in the information provided herein.
Signature Of Company Officer
*
Date
*
MM slash DD slash YYYY
Title
*
Company Name
*
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