SUBCONTRACTOR/SUPPLIER PRE-QUALIFICATION FORM
Today’s Date _____/_____/_____
SUBCONTRACTOR CONTACT INFORMATION
Physical (Street) Address
Office Phone No
Other Contact Number
Mailing Address (PO Box)
Has contractor conducted business under a different name? Yes
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 $___________________
________ ________ Yr.__________ Profit/Loss $___________________
________ 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
Bank Relationship Officer Name
Can Trade Contractor Bond this project?
Bonding Agency Name
Single Job Bonding Limits $
Aggregate Bonding Limits $
Bond Rate $
Bonding Agency Relationship Officer Name
Insurance Agency Attach Insurance Cert
Insurance Agency Contact Name
(Auto & General Liability, Workers Comp)
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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