GENERAL BUSINESS INFORMATION

Full Legal Name of Firm / Date:
Trade Name or DBA / Type of Service Provided
Mailing Address
City / State / Zip Code / Website Address
Telephone No. / Fax No. / Contact Name/Title / Email Address
Shipping Address Same as mailing address
City / State / Zip or Postal Code
Requests for quotation should be sent to (contact name, title, include address if different from above) / E-mail Address
Legal Name and Address of Parent Company (if applicable)
Legal Name of Subsidiary Company(ies) and Address(es) (if applicable)
Other Offices –ATTACH a list of sales offices, representatives, agents or contacts that act for your organization.
Include addresses, primary contact name, telephone and fax numbers. Include your international offices.

ORGANIZATION INFORMATION

Federal Tax ID Number / Duns Number / Years in Business / General E-mail Address
Corporation / Date Founded State of Formation
Partnership / Joint Venture / Proprietorship / Other (specify)
Subcontractor General Contractor Specialty Contractor Type:
Professional Service / Manufacturer / Other (specify)
BUSINESS SIZE AND OWNERSHIP CLASSIFICATION
NOTE: Any person who misrepresents a firm as a small or disadvantaged business concern is subject to punishment by a fine, imprisonment, or both.
Small Business If yes, see below / Minority Owned? / If yes, see below
Large Business / Woman Owned? / If yes, see below
Small Disadvantaged? / If yes, attach copy of certification
Other ______/ If yes, attach copy of certification
If Small Business, attach a copy of certification
Number of Employees / Annual Revenue $ / Name of Owner(s)
If Minority Owned Business, attach a copy of certification
Minority Ethnic Group(s) / Name of Owner(s)
If Woman Owned Business,attach a copy of certification
Name of Owner(s)
ORGANIZATION PERSONNEL
Officer’s Name / Title / Length of Service
UNION AFFILIATION
Union / Yes No / If yes, which union(s)
Contract expiration date(s)
Is your company registered with the National Maintenance Agreement? Yes No

PERFORMANCE

Has your organization ever failed to complete any contracted (purchase order) work? Yes No

If yes, explain

Are there any pending or outstanding claims, suits or judgments against or brought by your organization or principals? Yes No

If yes, explain

Has your company worked on projects having liquidating damages clause? Yes No

FINANCIAL
ATTACH a copy of your three most recent annual report or certified financial statement or balance sheet. Pre-qualification of your organization cannot be completed without this information. NOTE: This information will be held in strict confidentiality.
Annual Sales (in U.S. Dollars) for last three years
20 / $ / 20 / $ / 20 / $
Dun and Bradstreet Rating
Bonding Capacity
Per Project $ / Aggregate Capacity $ / Bonding Rate
Bonding Company / Bonding Agent
Address / City / State / Zip
Bonding Co. or Agent Contact / Telephone No / Email
Banking Reference
Name of Bank / Line of Credit $
Address / City / State / Zip
Bank Contact / Telephone No / Email
INSURANCE
ATTACH a copy of your current insurance certificate.
Name of Insurance Company / Insurance Agent
Address / City / State / Zip
Insurance Co. or Agent Contact / Telephone No / Email
Total General Liability per Project $ / Total Excess/Umbrella Liability per Project $

REFERENCES

List major clients that you have performed work or services for within the past five (5) years. Attach a separate list if necessary.
Company / Location / Contact / Telephone No.
CONSTRUCTION EXPERIENCE
Recent Construction Experience (Past 3 years) Note: Provide additional projects on a separate sheet
Project Name & Location / Contract Amount $
General Contractor / Contact Name
Date Completed / Telephone
Project Name & Location / Contract Amount $
General Contractor / Contact Name
Date Completed / Telephone
Project Name & Location / Contract Amount $
General Contractor / Contact Name
Date Completed / Telephone
Construction In Progress Note: Provide additional projects on a separate sheet
Project Name & Location / Contract Amount $
General Contractor / Contact Name
Start Date / Expected Finish / Telephone
Project Name & Location / Contract Amount $
General Contractor / Contact Name
Start Date / Expected Finish / Telephone
Project Name & Location / Contract Amount $
General Contractor / Contact Name
Start Date / Expected Finish / Telephone
CONSTRUCTION EXPERIENCE WITH MJE
Has your firm previously worked with M. J. ELECTRIC? Yes No If yes, list projects below
Project Name / Location / Office/Subsidiary / Date

COMPANY SAFETY INFORMATION: (Please be as complete as possible)

Does your company have a written safety/health program? Yes No If yes, please attach a copy of program.
Does your company have designated Safety & Health representatives? Yes No
If yes, how many? If no, who is responsible for safety audits?
Name & title of Safety & Health contact
Qualifications, Training, and Certifications of contact
Does your company comply with all state and federal regulations? Yes No
Does your company currently conduct regularly scheduled safety meetings? Yes No Are they required? Yes No
What is the frequency of on-sitesafety meetings?
What is the frequency of on-site inspections?
Does your company have a safety orientation for new employees? Yes No
Does your company currently have a training program? Yes No
Is the training program documented? Yes No If yes, provide a copy of the training program and documentation for program.
Does your company have a written substance abuse program? Yes No If yes, please attach a copy of program.
Will your substance abuse policy require testing for all employees not less than 14 days prior to arriving on MJE’s site? Yes No
Does your company require subcontractors to meet the same safety standards? Yes No
Does your company set annual safety goals? Yes No
If yes, list current goals
Does your company have a Safety Incentive Program? Yes No
If yes, please describe
Does your company safety program include the following procedures/training? (Please check all that apply)
Accident Investigation
Alcohol Abuse
Aerial Equipment
Blood Borne Pathogens
Confined Space Entry
Controlled Substance Abuse
Defensive Driving
Electrical Safety
Emergency Response
Excavation/Trenching
Fall Protection / Fire Protection & Prevention
First Aid
Hazard Communication/MSDS
Hazardous Energy Control
Heavy Equipment Operation
Housekeeping
Industrial Hygiene
Injury Reporting
Ladder Safety
Lockout/Tagout
Personal Protection
Post-Accident Testing / Powered Industrial Trucks
Pre-employment Drug Testing
Random Drug Testing
Respiratory Protection
Safety Policy
Safety Rules
Scaffolding
Subsurface Clearance
Tool Safety
Welding, Cutting and Hot Work
Work Hazard Reporting

COMPANY SAFETY EXPERIENCE: (Please be as complete as possible)

Standard Industry Classification (SIC) number(s) / or corresponding NAICS number(s)
Number of OSHA Citations
(Explain any citations in comments) / Current Year / 20 / 20 / 20

Summary of Work Related Injuries and Illnesses from OSHA Form 300A (Attach copies from the last 3 years)

YEARS / Current Year / 20 / 20 / 20
Employment Information
Annual Average Number of Employees
Total Man-Hours Worked
Rates
EMR (Attach a verification letter on insurance company/agent letterhead)
Total Case Incident Rate (TCIR) (Explain major changes in Comments)
Lost Work Case Incident Rate (LWCIR)
Number of Cases
Number of OSHA Recordable Cases
Days Away From Work Cases
Job Transfer or Restriction Cases
Other Recordable Cases
Number of Fatalities
Number of Days
Number of Days of Job Transfer or Restriction
Number of Days Away From Work
Comments
* NOTE - Total recordable rates are calculated by multiplying the number of logged cases by 200,000 and dividing the product by the total hours worked.
The information provided herein is true and sufficiently complete so as not to be misleading.
Signature of Information Provider Title/Position Date

INTERNAL USE ONLY (To be completed by M. J. ELECTRIC) Compliant Non-Compliant

Date Received / MJE Vendor Code / Did Supplier provide Safety Manual? Yes No

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