SUBCONTRACTOR PREQUALIFICATION FORM

Submitted By:
Company Name:
Address:
City/State:
Phone Number:
Fax Number:
Contact Person:
Email Address:
Website:
Virginia Contractor's License #
1. List the work that your company normally performs with its own forces:
2. How many years has your company been in business under its present name?
3. Has your company ever failed to do any work awarded to it?

   If so, Please explain:

4. Current jobs in progress:
Name & Location
Contractor/Owner
Phone#
Contract Value
$
$
$
$
$

5. Banking refrences:
Bank
Contact Person
Phone#

6. Credit refrences:
Vendor Name
Contact Person
Phone#

7. Bonding Information:
Surety(Company that issue bond):
Bonding Agent's name & phone number:
Bonding capacity (single job):
$

8. Approximate sales volume for the past three (3) years:
20
$
20
$
20
$

9. Largest project completed in the last three (3) years:
$

10. Small Business Enterprise?
Yes No

11. Minority Business Enterprise?
Yes Type:
No

12. Experience Modification Rate(EMR)for Workers Compensation Insurance

    Current Year: %     Previous Year: %

13. OSHA Incidence Rates:

    Prior Year:     Second Prior Year:

14. Size range of jobs interested in bidding:

    Low: $     High: $

15. Indicate geographic areas in which you are interested in bidding:

16. List the labor organizations with which your company is affiliated, if any

17. Do you have any objections to us contacting your previous clients or credit references?

     Yes     No
By executing below, I am acknowledging that McKenzie Construction Corporation will be relying upon the accuracy of the above information to assist them in determining, at their discretion, whether my organization will be selected to provide services on their construction projects.


Name Of Organization:
By:
Title:
Date:

1711 Mediterranean Ave,
Virginia Beach,
VA 757.422.6177