Subcontractor Pre Qualification Application (Page 5 of 6) in pdf

Subcontractor Pre Qualification Application Page 5

D. Has your company received any safety violations or fines in the past five (5)

years? _____

If so, please describe details:

______________________________________________________________

6. Financial Information

Complete the financial information below:

Current Assets

$_____________________

Fixed Assets

$_____________________

Other Assets

$_____________________

TOTAL ASSETS

$_____________________

Banking Institution:

___________________________________________

Contact Name:

___________________________________________

Telephone Number:

__________________________________________

Date of latest Certified Balance Sheet ________________________ prepared by

________________________________________________________________

Is the latest Certified Balance Sheet available upon request? _____

Do you have a Dunn & Bradstreet number? _____

If so, list number ___________________________

7. Current Workload

List current projects underway, contract dollar value, location and general

contractor working for:

________________________________________________________________

The undersigned hereby certifies under oath that the information provided herein is true

and sufficiently completed as not to be misleading.

Signature: _______________________________________

Dated this ______day of ______________________, 2006.

Page 5 of 6

Subcontractor Pre Qualification Application Page 5