Company Identity

Company Name

Address

Mailing Address (if different)

Phone Number

Fax Number

Website

Point of Contact

Point of Contact Email*

DUNS

CAGE CODE

TIN/EIN

Registered in Central Contractors Registration (CCR)?

Yes
No

Type of Organization

Sole ProprietorshipPartnershipCorporate Entity (non-tax exempt)Corporate Entity (tax exempt)Government Entity (Federal, State, or Local)Foreign GovernmentInternational organization (per CFR 1.6049-4)Other (explain)

Other Explain

Date Company Formed?

In What State?

Common Parent Company

Owned or controlled by common parent?

Yes
No

Name and TIN/EIN of common parent?

Name

TIN/EIN

Company Revenue

Company's average annual gross revenue for the last three accounting years?

North American Industrial Classification System

Primary NAICS Code

Other NAICS (separate each code with a ";" or ",")

Size of Project Preferred ($)

Geographic Location Preferred

Largest Single Project to date ($)

Statement of Qualifications

Does your firm have an SOQ or marketing brochure?

Yes
No

Small Business Status (check all that apply)

Small Business Concern
Woman-Owned
Minority-Owned
Veteran-Owned
Service Disabled Veteran Owned Business
HUBZone
SBA 8(a) certified Small Disadvantaged Business
SBA Super 8(a) - qualified Alaska Native Corporation or Native American Organization
Not a small business

I am interested in participating in RBA's Small Business Support program

Bonding Capacity

Are you able to bond projects?

Yes
No

Bonding Rate (%)

Single Project Limit ($)

Aggregate Limit ($)

Surety Company Name

Agent Name

Agent Phone Number

Number of Employees

Salaried

Hourly

Insurance Information

Workers Compensation Experience Modification Rate (EMR)

Most Recent EMR

Effective Date

General Liability Limits

Per Occurrence ($)

Aggregate ($)

Insurance Company

Insurance Agent Name

Insurance Agent Phone Number

Banking Reference

Bank Name

Bank Point of Contact

Bank Point of Contact Phone Number

Completed Projects (List 4 within past 5 years)

Project 1

Project Name

Contracting Entity

Point of Contact

Point of Contact Phone Number

Contract Amount

Completion Date

Project 2

Project Name

Contracting Entity

Point of Contact

Point of Contact Phone Number

Contract Amount

Completion Date

Project 3

Project Name

Contracting Entity

Point of Contact

Point of Contact Phone Number

Contract Amount

Completion Date

Project 4

Project Name

Contracting Entity

Point of Contact

Point of Contact Phone Number

Contract Amount

Completion Date

Current Projects Underway (List 4)

Project 1

Project Name

Contracting Entity

Point of Contact

Point of Contact Phone Number

Contract Amount

Percent Complete

Project 2

Project Name

Contracting Entity

Point of Contact

Point of Contact Phone Number

Contract Amount

Percent Complete

Project 3

Project Name

Contracting Entity

Point of Contact

Point of Contact Phone Number

Contract Amount

Percent Complete

Project 4

Project Name

Contracting Entity

Point of Contact

Point of Contact Phone Number

Contract Amount

Percent Complete

Trade References

Reference 1

Company Name

Address

Point of Contact

Point of Contact Phone Number

Reference 2

Company Name

Address

Point of Contact

Point of Contact Phone Number

Reference 3

Company Name

Address

Point of Contact

Point of Contact Phone Number

Client References

Reference 1

Company Name

Address

Point of Contact

Point of Contact Phone Number

Reference 2

Company Name

Address

Point of Contact

Point of Contact Phone Number

Reference 3

Company Name

Address

Point of Contact

Point of Contact Phone Number

Other Information

In the past 5 years has the company:

Operated under any other name?

Yes
No

Had any liens or bond claims filed against its projects by any of its subcontractors or suppliers?

Yes
No

Ever failed to complete a contract, been defaulted, or had a contract terminated?

Yes
No

Had liquidated damages assessed for work performed?

Yes
No

Had any of its key people as a party to a bankruptcy or reorganization proceeding?

Yes
No

Had any of its key people involved in any lawsuit arising from a project or accident?

Yes
No

Had any of its key people investigated for or found to have committed a violation of labor laws?

Yes
No

Had any of its key people investigated for or found to have committed a serious OSHA violation?

Yes
No

Had any of its key people investigated for or found to have committed a violation of state/federal/local laws?

Yes
No

Give explanation for any "yes" answers

Document Upload

Certificates of Insurance

Copy of last 3 years EMRs

Copy of current OSHA 300/300A Log

Electronic SOQ or marketing brochure

Standard Labor Rate Sheet (if applicable)