Subcontractors

Business Type
- Corporation
- Partnership
- Limited Liability Company (LLC)
- Sole Proprietor
List the name, title, years with the company and percent of ownership of the company's principals
Name Title Years with Company Percent Ownership
Is your company owned or controlled by a parent company or any other organization?
- Yes
- No
If yes, brief explanation
Check applicable certification(s)
- MBE
- WBE
- DBE
- VBE
- SBE
- Native American
Provide number of
Office Personel Field Supervisors Average Field Labor Average Shop Labor

Are there any judgements, claims, arbitration proceedings or suits pending/outstanding against your firm or its officers or principals?
- Yes
- No
If yes, attach a complete explanation.
Has your company filed any lawsuits or requested arbitration or mediation with regard to construction contracts within the last three (3) years?
- Yes
- No
If yes, attach a complete explanation.
Has your company or any other organization with which your officers were involved during the last three (3) years ever been in bankruptcy or a voluntary or involuntary reorganization?
- Yes
- No
If yes, attach a complete explanation.
Has your company, or any other organization with your current officers, ever fail to complete a project?
- Yes
- No

Annual Income
What was the average annual revenue from work completed in the last three (3) years and, what is next year's forecasted revenue?
Year Revenue
Forecasted revenue next year
To pre-qualify for more than a $50,000 contract, attach copies of your most recent annual financial statements (balance sheet, income statement and cash flow). If your annual statements are more than six months old, please also include current quarterly statements. IMPACT Strategies uses this information strictly for prequalification purposes and will not disclose your financial information to any third parties.

OSHA Record
Has your firm had any OSHA citations, fines or jobsite fatalities within the most recent three (3) years?
- Yes
- No
If yes, please leave a detailed description of the incident and the steps taken to prevent a recurrence.
Lost workday cases for the last 3 years recorded on OSHA Form 200.
Workers' Compensation
Please list your firm's workers' compensation experience modification rate (EMR) for the last three (3) years
Year Rate
Do you have a written safety program?
- Yes
- No

Trade Categories
Select the primary categories of work you would normally perform.
Has your company had experience with LEED-certified projects?
- Yes
- No
Geographic Areas of Work
Please check only locations in which you want to bid.
- St. Louis/Metro East
- Central Illinois
- Midwest
- Southern Illinois
- St. Louis City
- Missouri
- Other
Project Types
Please check the type of building projects your company has completed.
- Health Care
- Hospitals
- Warehousing
- Custom Homes
- Assisted Living Industrial Schools
- Hospitality Retail
- Clubhouse/Spa Office Multihousing/Dorms
- Other
Contract Method
Please indicate the percentage of your work load for each contract method
% Competitive Bid % Negotiated/Design Assist % Design Build

Performance References
Provide five references below. Each reference should be from a different general contractor. These references should be for work completed in the last five years and should be representative of the work you are trying to pre-qualify for now. One reference must be for your performance on your largest project within the last two years and two references must be on current projects. NOTE: The contact provided must have direct knowledge of your performance on that project. Leaving out any of the contact information including the email address will delay the processing of your application.
1.
Project Name/Type
General Contractor
Subcontract Value
Contact Name
Contact Email
Contact Phone
Contact Fax
2.
Project Name/Type
General Contractor
Subcontract Value
Contact Name
Contact Email
Contact Phone
Contact Fax
3.
Project Name/Type
General Contractor
Subcontract Value
Contact Name
Contact Email
Contact Phone
Contact Fax
4.
Project Name/Type
General Contractor
Subcontract Value
Contact Name
Contact Email
Contact Phone
Contact Fax
5.
Project Name/Type
General Contractor
Subcontract Value
Contact Name
Contact Email
Contact Phone
Contact Fax

Union Affiliation
Please attach any additional information to help us determine your company's qualifications and expert.
Union Local Contact Person Contact Phone

Signature
By my signature below, I hereby provide my formal authorization for any Reference company above to discuss our business relationship with any executive of IMPACT Strategies, Inc. who may inquire from time to time. This information may include but not be limited to: the length of our business relationship, our outstanding and available credit with the reference company, the maturity date of our loans and likeliness of renewal, our repayment record on loans or credit balances, and the average of our deposit balances, and record, if an, of overdraft activity or delinquencies.
Name
Title
Phone
Prepared By

State	Number

Name	Title	Years with Company	Percent Ownership

Year	Revenue

Year	Rate