Subcontractor/supplier Pre -Qualification Form

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(Please Print)
Today’s Date _____/_____/_____
Company Name
DNB Number
Primary Contact
Secondary Contact
Physical (Street) Address
ZIP Code
Office Phone No
Fax Phone
Cell Phone
Email Address
Other Contact Number
Mailing Address (PO Box)
ZIP Code
Has contractor conducted business under a different name?  Yes
 No
If Yes, provide name(s)
Tax ID No. (TIN)
Date Company Established
Total No. Employees
Contractor’s License No(s) and Classification(s)
Gross Revenues (last 3 years)
Current Backlog (include committed work)
$_______________________ Yr.__________ Profit/Loss $___________________
Total Value
________ ________ Yr.__________ Profit/Loss $___________________
% Complete
________ Yr.__________ Profit/Loss $___________________
No of Projects
Please attach copies of the prior year ending Income Statement and Balance Sheet,or Audited Financial Statements. In addition, provide current
internal YTD Balance Sheet, Income Statement, as well as Accounts Payable and Accounts Receivable with aging.
Bond / Legal Claims
Please list all open and satisfied legal and bond claims in the last two years.
Scope of Work / Trade
Primary Bank Name/Address
Account Number
Bank Relationship Officer Name
Phone Number
 Yes
 No
Can Trade Contractor Bond this project?
Bonding Agency Name
Single Job Bonding Limits $
Aggregate Bonding Limits $
Bond Rate $
Bonding Company
Bond Rating
Bonding Agency Relationship Officer Name
Phone Number
Insurance Agency Attach Insurance Cert
Insurance Agency Contact Name
(Auto & General Liability, Workers Comp)
Phone Number
What is your EMR (experience modification rate)?
By signing this document below, Subcontractor hereby authorizes its primary bank relationship officer to release general information requested by
Native American Services Corp. as part of its due diligence and Financial Review process.
NASCO Form #OP-48.2
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