(Complete the form below, insert on Company letterhead, and return to:

Bert Schnettgoecke, P.E.

Senior Project Engineer – Facilities and Parks

City of Shawnee

11110 Johnson Drive

Shawnee, KS 66203

Office: 913-742-6271

Fax: 913-248-2314

Email: )

SUBCONTRACTORQUALIFICATION STATEMENT

FOR

SHAWNEE TOWN 1929

ORGANIZATION

Company Name:

Street Address:

(City, State, Zip)

Mailing Address:

(City, State, Zip)

Phone: Fax:

Company Website:

Contact Name: Cell Phone:

Contact Email Address:

Name of Parent Company:

Address of Parent Company:

(City, State, Zip)

Under what other or formernames has the Company operated?

Type of Company: □ Corp.□ Partnership□ Proprietorship□ Sub. S. Corp.

If Corporation, please provide the following:

State of incorporation Date of incorporation

President's name

Vice President's name(s)

Secretary's name

Treasurer's name

If Partnership, please provide the following: Date of organization

Type of partnership (if applicable)

Name(s) of general partner(s)

If Individuallyowned, provide the following: Date of organization

Name of owner

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

How many staff members are presently employed:

Home Office Field Supervisory Trades People

LICENSING AND REGISTRATION

Provide jurisdictions in which Company is legally qualified to practice. Indicate license or registration

number for each jurisdiction, if applicable, and type of license or registration.

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?

Are there 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 contracts 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?

EXPERIENCE

List categories of work your Company normally performs with its own forces:

Check all types listed below on which your Company has worked:

Commercial / Multi-Family Residential
Light Commercial / Site Development
Residential

Percentage of work the Company normally subcontracts:

Attach a list construction projects your organization has in progress, including the following:

  • name of project
/
  • scope of work

  • owner reference, including contact information
/
  • percent complete

  • architect reference, including contact information
/
  • scheduled completion date

  • contract type and amount

State total value of work currently in progress and under contract: $

Attach a list the projects your organization has completed in the past five years, including the following:

  • name of project
/
  • scope of work

  • owner reference, including contact information
/
  • contract type and amount

  • architect reference, including contact information
/
  • completion date

State average annual amount of construction work performed during the past five years: $

KEY PERSONNEL

Provide information below for key personnel available to work on the project.

Name: ______

Position: ______

Years with Company: ______

Total Years Relevant Experience: ______

Construction Experience: ______

Name: ______

Position: ______

Years with Company: ______

Total Years Relevant Experience: ______

Construction Experience: ______

Name: ______

Position: ______

Years with Company: ______

Total Years Relevant Experience: ______

Construction Experience: ______

REFERENCES

Bank: Name, address, contact person,and phone

Contractors or Vendors:Name, address, contact person,and phone

Owners: Name, address, contact person, and phone

FINANCIAL /SURETY

Surety: Company name, address, agent’s name, and phone

Bonding capacity currently available:

If no bonding available, attacha copy of most recent financial statement.

SAFETY

Attach a letter from your insurance carrier verifying your Company’s Workers’ Compensation Interstate/Intrastate Experience Modification Rate (EMR) for the most recent three years.

Do you have a qualified person responsible for safety within the Company?

Describe his/her qualifications:

Does the Company have a written Safety Policy and Program and will you provide if requested?

Does the Company have a substance abuse policy?

Does the Company have a person performsafety inspections on all of your projects, and if so, with what frequency?

The undersigned, on behalf of (insert Company name)certifies the information provided herein is true and sufficiently complete.

Signature: ______

Print Name: ______

Title: ______

Date: ______

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