Fillable Subcontractor/supplier Pre -Qualification Form (Page 2 of 2) in pdf

Subcontractor/supplier Pre -Qualification Form Page 2

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SUBCONTRACTOR PRE-QUALIFICATION FORM – page 2

CLIENT AND SUPPLIER REFERENCES (a minimum of 3 each)

Company Name

Contact Name

Phone & Fax Numbers

Client 1

Client 2

Client 3

Supplier 1

Supplier 2

Supplier 3

SAFETY

 Yes

 No

Do you have a written Safety Program?

If Yes, briefly describe scope:

 Yes

 No

Job related employee deaths?

If Yes, please give explanation

 Yes

 No

Any OSHA citations?

If so, briefly describe

 Yes

 No

Company Safety Officer?

If so, note contact name and phone number:

RECENT PREVIOUS PROJECTS

Project / Location

Client Name

Total Value $

By signing, I acknowledge that this document does not constitute a contract award and that NASCO utilizes this document, attachments, and supporting

data provided by me and my organization in its consideration of a subcontract award. Any awards will be issued via separate document at Nasco’s

discretion. I certify that I am authorized to bind my organization through the signing of this document, and may be held responsible as a representative of

my organiation for any material omissions, mis-statements, or inaccuracties that would have otherwise averted NASCO from awarding a subcontract to

the company that I represent. Any and all supporting documents provided by my firm are accurate, prepared according to Generally Accepted Accounting

Prinicipals, and are a true reflection of the financial health of my organization as of the signing of this document.

Authorized Representative Name: _______________________________________ Date:________________________

Authoried Representative Signature:______________________________________

NASCO Form #OP-48.2

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