SUB PREQUAL FORM. prequalificatiom form information WE USE TEXTURA! Who requested prequal from R. C. Stevens? Check it out at

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1 SUB 2014 PREQUAL FORM WE USE TEXTURA! Check it out at R. C. Stevens Construction Company has automated our monthly payment application process by leveraging an online application provided by Textura Corporation. prequalificatiom form information Who requested prequal from R. C. Stevens?

SUBCONTRACTOR QUALIFICATION FORM Instructions: Elaboration of the following requested information or additional information deemed to be useful for evaluation of your firm s capabilities may be

2 SUBCONTRACTOR QUALIFICATION FORM Instructions: Elaboration of the following requested information or additional information deemed to be useful for evaluation of your firm s capabilities may be attached to this form. Your completed Qualification Form will be maintained and utilized by R. C. Stevens Construction Co. as a basis for determining bid sources. Some R. C. Stevens Construction Co. projects may require more current information and the resubmission of this form by your firm. From the attached list, please insert applicable Code Number in Contracting Interest section. PLEASE LIMIT THE NUMBER OF ATTACHMENTS TO A MAXIMUM OF THREE PAGES. WE WILL CONTACT YOU FOR ANY ADDITIONAL INFO IF NEEDED. 28 S. Main Street Winter Garden, FL (407) fax (407) Date: Vendor No: Name of company: Mailing Address: City: State: Zip: - Street Address: City: State: Zip: - Telephone:( ) Fax:( ) Union Affiliations: Local: National: (IF YOUR COMPANY ADDRESS IS DIFFERENT FOR REMITTANCE PURPOSES, PLEASE INDICATE BELOW): Remittance: Street Address: City/State/Zip: Federal Identification Number: Social Security Number (if sole owner): Indicate type of business organization: Corporation Partnership Sole Owner Yrs. in business under present name: If Corporation or Partnership, list names of Officers/Partners: Yrs. performing work specialty: Work now under contract $: % of work performed by own forces: Work in place last year $: State in which incorporated: Date of incorporation: Main Contact Person & Title: Estimator: Avg. annual sales last 3 yrs.$ Address (FOR BID NOTIFICATION): State/County/City license(s) holder(s) (and numbers): - PRIMARY Contracting interests (select CSI code # only from attached list - select only the trades for your PRIMARY contacting interest - would you provide a proposal to us for this work as a standalone trade, exclusive of your PRIMARY trade?). Geographic area of business operation: All FL Cent. FL N FL SW FL SE FL SE USA (GA, AL MI, Total Bonding Capacity $: Value of work presently bonded $: Dun & Bradstreet Number: Bonding Co.: Bonding Company Best Rating: Agent: Phone #: - K:\subcontractor project related forms\prequalification Forms\Sub Prequalification Form 2014.docx 1 Revision 4/29/2014

3 Bank references (include address, phone number, contract person): R.C. Stevens insurance Requirements are as follows: General Liability $2,000, Auto Insurance $1,000, Excess Coverage $1,000, Worker s Comp. $500, Current Experience Modification Rate: Last Year: Insurance Agent s Name (include address, phone number, contact person): Total employed by firm: Sales/estimators: Project Mgrs.: Clerical: Field: Approx. value of capital equipment owner by firm: In-house Engineering or Fabrication capability: Fabrication floor area: SF Is Firm in compliance with all EEO requirements: Yes No Is Firm qualified as a WBE City, County, State certified in: (enclose copy of certification) Is Firm qualified as a MBE City, County, State certified in: (enclose copy of certification) Does firm have a written work place Safety Program and Policy? Yes No Does firm have a written Drug Free Work Place Policy? Yes No Does firm have an orientation program for new employees? Yes No Has Firm: Failed to complete a contract ; been involved in bankruptcy or reorganization ; have any pending judgments, claims or suits against firm?. (If the answer to any preceding is yes, please submit details on separate sheet.) In the previous three years has your firm been cited for a serious (as defined by O.S.H.A.) violation? Yes If yes, explain: No Has firm worked on State of Florida AHCA inspected projects within the past three (3) years? Yes No (If yes, state Specific Project Names, Facilities and Locations where work performed, and name of prime General Contractor): K:\subcontractor project related forms\prequalification Forms\Sub Prequalification Form 2014.docx 2 Revision 4/29/2014

4 List the four (4) most significant projects completed in the last five (5) years: PROJECT/LOCATION GEN L CONTRACTOR CONTRACT AMT DATE COMPLETED CONTACT & PH. # (1) (2) (3) (4) List the three (3) most significant projects presently under construction: PROJECT/LOCATION GEN L CONTRACTOR CONTRACT AMT AWARD DATE CONTACT & PH. # (1) (2) (3) This form must be signed by an Officer of the firm or an individual so authorized by an Officer of the firm. Signature: Name: Title: FOR INTERNAL USE ONLY -- DO NOT FILL-IN REFERENCE CONTACTED DATE CONTRACT REMARKS BONDING CO. CONTRACTED BANK CONTACTED RECOMMEND THIS FIRM BE PLACED ON BIDDER LIST. DO NOT RECOMMEND THIS FIRM BE PLACED ON BIDDER LIST, BECAUSE DUNN & BRADSTREET REQUESTED: K:\subcontractor project related forms\prequalification Forms\Sub Prequalification Form 2014.docx 3 Revision 4/29/2014

5 SELECT ONLY YOUR PRIMARY WORK TRADE INTEREST Code Construction Layout & Survey Photographic Documentation Testing & Inspection Services Construction Waste Management and Disposal Temporary Fencing Field Office Trailers Temporary Cranes & Hoists Temporary Scaffolding and Platforms Final Cleaning Demolition Saw Cutting Asbestos Abatement Dewatering Erosion Control / Retaining Walls Sitework Pressure Grouting Soil Stabilization Termite Control Piling & Sheeting Unit Paving Paving & Surfacing Pavement Markings & Seal Coatings Traffic Signalization Utility Directional Drilling and Pipe Jacking Wells Underground Utilities, Storm, Sewer, Water Trench Drains Precast Septic Tanks Fountains & Water Features Chain Link and Wood Fences and Gates Fences and Gates Playground Equipment Site Furnishings Landscape, Irrigation, Sod & Seed Concrete Reinforcement Cast-in-Place Concrete Architectural Concrete/Hardscape Post-Tensioned Concrete Concrete Pumping Precast Structural Concrete Precast Architectural Concrete Precast Concrete Specialties Tilt-Up Concrete and Insul Wall Lightweight Concrete Concrete Unit Masonry Structural Steel & Welding Light Gauge / Steel Trusses / Cold Formed Unistrut Miscellaneous Metal, Stairs & Railings Metal Covers Expansion Joint and Column Rough Carpentry Wood Framing Lumber Suppliers Heavy Timber & Glue Lam Wood Trusses Finish Carpentry & Trim Cabinet & Case Work Glass-Fiber-Reinforced Plastic Shapes Code Countertops - Stone & Composit Caulking & Waterproofing Insulation - Thermal / Batt / Board Fireproofing - Spray On Firestopping Roofing - Asphalt Shingles & Tile Roofing - Metal Roof Panels Roofing - Built-Up Bituminous & Membrane Roofing - Specialties Gutters & Downspouts Doors Frames and Hardware Powered Door Opening Assemblies Composite Doors FRP Industrial Doors and Grilles Impact Doors Overhead & Sectional Doors Entrances and Storefronts Windows Large Custom Framed Skylight Systems Stucco / Plaster / EIFS Gypsum Board Assemblies and Metal F Ceramic Tiling Acid Resistant Flooring Terrazzo Flooring Stone Work Acoustical Ceilings Wood Flooring Resilient Flooring and Carpet Epoxy / Seamless Fluid-Applied Flooring Sand Blasting and Hydro Blasting Painting and Wallcovering Visual Display Surfaces and Signage Louvers Wall and Door Protection Access Flooring - Raised Steeples Flagpoles Pedestrian Control Crowd Line Rope Lockers Fire Extinguishers & Cabinets Awnings / Sunscreens / Walkway Coverings Postal Specialties Operable Partitions Storage Assemblies & Racks Telephone Specialties Toilet Accessories Cubicle Curtains Track and Hardware Bank Equipment Religious Equipment Theater and Stage Equipment Audio-Visual Equipment Vehicle Service Equipment Parking Control Equipment Loading Dock Equipment Solid Waste Control Equipment Trash Chutes Food Service Equipment K:\subcontractor project related forms\prequalification Forms\Sub Prequalification Form 2014.docx 4 Revision 4/29/2014

6 Code Residential Appliances Athletic Equipment Laboratory Equipment Office Equipment & Furniture Window Blinds and Treatments Entrance Floor Mats and Frames Bleachers / Seating / Grandstands Clean Rooms Cold Storage Doors & Panels Prefabricated Booths Radiation Protection Mini Storage Specialties Metal Building Systems PEMB Erectors Swimming Pools Material Storage Tanks - Food Process Piping, Equipment & Controls Elevators Code Specialty Material Handling Equipment Conveyors Pneumatic Tube Systems Cranes and Hoists Fire-Extinguishing Systems Plumbing Med Gas & Oxygen Piping Compressed-Air Systems / Pneumatic Piping HVAC Chemical Water Treatment Refrigeration Processes Testing Adjusting and Balancing Electrical Generator Assemblies Fire Detection and Alarm Lightning Protection Low Voltage Communications Voice Data Structured Cabling K:\subcontractor project related forms\prequalification Forms\Sub Prequalification Form 2014.docx 5 Revision 4/29/2014

Name of company: Mailing Address: City: State: Zip: - Street Address: City: State: Zip: -

Name of company: Mailing Address: City: State: Zip: - Street Address: City: State: Zip: - SUBCONTRACTOR QUALIFICATION FORM Instructions: Elaboration of the following requested information or additional information deemed to be useful for evaluation of your firm s capabilities may be attached