Subcontractor Statement of Qualifications Legal Name of Firm* Trades Performed* Street Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*FaxCellMailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Contact Name First Last Contact Email Certified MBE DBE WBE N/A Agencies Certified With Pima County City of Tucson ADOT TAA Arizona Contractor's License (Number/Class/Expiration) Arizona Contractor's License (Number/Class/Expiration) ReferencesList three major suppliersSupplier 1 Company Name: Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneContact Name First Last Supplier 2 Company Name: Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneContact Name First Last Supplier 3 Company Name: Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneContact Name First Last ReferencesList three General Contractors with whom you do businessGeneral Contractor Reference 1 Company Name: Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneContact Name First Last General Contractor Reference 2 Company Name: Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneContact Name First Last General Contractor Reference 3 Company Name: Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneContact Name First Last Revenue Past Five Years:2020Include Revenue ($), Largest Contract, General Contractor2019Include Revenue ($), Largest Contract, General Contractor2018Include Revenue ($), Largest Contract, General Contractor2017Include Revenue ($), Largest Contract, General Contractor2016Include Revenue ($), Largest Contract, General ContractorCurrent Bonding, Insurance, & Banking InformationSurety Surety Contact Person First Last Contact PhonePlease attach a letter from your surety detailing the single projection and aggregate amounts they will issue a performance and payment bond for this project*Max. file size: 32 MB.Name of Insurance Insurance Contact Person First Last Insurance Contact PhonePlease attach a current copy of your insurance certificates. Contractor and owner will be required to be listed as additionally insured for this project if a Subcontract is executed.* Drop files here or Select files Max. file size: 32 MB. Name of your bank Bank Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Bank Contact Person First Last Bank Contact PhoneA copy of your latest financial statements prepared by an outside accounting firm and a copy of your most recent Internal Financial Statement must be provided. This information will be kept confidential.* Drop files here or Select files Max. file size: 32 MB. Completed By: First Last Title: Date MM slash DD slash YYYY Project Performance InformationUpload a list major construction projects your firm has subcontracted and completed in the past three to five years. Do not list current work on this sheet.* Drop files here or Select files Max. file size: 32 MB. Provide the following information: - Project Name/Description - Agency/Owner - Total Construction Cost - Date Completed - Reference Name, Phone and Email Upload a list major construction projects for which your firm is currently subcontracted. Do not list completed projects on this sheet.* Drop files here or Select files Max. file size: 32 MB. Provide the following information: - Project Name/Description - Agency/Owner - Total Construction Cost - Scheduled Completion Date - Reference Name, Phone and EmailSafety Performance QuestionaireSafety Contact: First Last PhoneEmail 1) OSHA Reporting Safety InformationProvide the number of OSHA recordable injury cases for the past three years.202020192018 Provide the number of OSHA recordable incident rate for the past three years.202020192018 Provide the number of lost time accident/illness for the past three years.202020192018 Provide the lost time accident/illness rate for the past three years.202020192018 Provide the number of fatalities for the last three years.202020192018 OSHA Log Administrator First Last Experience Modification Rate InformationProvide your Experience Modification Rate (EMR):Current202020192018 OSHA Citation InformationList the number of OSHA Citations received and upheld in the previous three (3) calendar years.2020# of Citations UpheldProvide Severity Rating (Non‐serious, serious, willful) 2019# of Citations UpheldProvide Severity Rating (Non‐serious, serious, willful) 2018# of Citations UpheldProvide Severity Rating (Non‐serious, serious, willful) 4) Does your company have a PRE‐HIRE substance testing program? Yes No 5) Does your company have a MANDATORY POST‐ACCIDENT substance testing policy? Yes No 6) Does your company have a written Safety Program? Yes No 7) Are safety goals developed and communicated? Yes No 8) Does your company hold tail‐gate safety meetings? Yes No If yes, who attends the meetings? All Employees Only Field Employees 9) Does your company conduct a pre‐project hazard analysis? Yes No (You may be required to submit a pre‐project hazard analysis)10) Does your company conduct safety orientation for ALL New‐Hire employees? Yes No 11) Does your company provide safety‐training classes for your employees? Yes No 12) Does your company conduct Accident and Incident Investigations? Yes No 13) Do the investigations identify root causes? Yes No 14) Are completed accident/incident reports distributed to management? Yes No 15) Does your company conduct Drivers License Record Verifications on all employees required to operate a company vehicle? Yes No 16) How frequently does you company conduct safety inspections? Daily Weekly Monthly Other If other, please describe: 17) Who conducts these safety inspections? Company Safety Representative Manager Supervisor/Foreman Insurance Representative Safety Consultant 18) Does your company document employee certifications for the specific equipment, job conditions, trades (i.e. forklift, manlift, CDL, crane, confined space, excavations, etc.)? Yes No If yes, please list the types of certifications maintained?19) Have your company’s supervisors and managers completed the OSHA 10‐hour course? Yes No 20) Your company’s General Liability Insurance limits are: Greater than $1,000,000/$2,000,000 $1,000,000/$2,000,000 Less than $1,000,000/$2,000,000 21) Have your flaggers successfully completed a Flagging Safety Course? Yes No 22) Has you company received a citation for violation of the Pima County Air Pollution Regulations? Yes No If yes, how many? OMITTING OR REPORTING FALSE INFROMATION ON THIS QUESTIONAIRE COULD RESULT IN REMOVAL FROM OUR MASTER BID LIST.Preparer's Signature:Date MM slash DD slash YYYY Corp. Officer/Owner’s Signature:Date MM slash DD slash YYYY Follow
