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John Carlo, Inc.
Subcontractor / Supplier
Qualification Form

Please make sure to complete this form in its entirety.  Do not leave any items blank.  Acceptable responses for items that do not have a formal response are: N/A – Not Applicable, Not at this time, Will not disclose information.

 

Company Name *
 
Address *
 
City *
 
State *
 
Zip *
 
Phone *
 
Fax
Website
Primary Owner *
Phone
Fax
Email
Primary Contact *
Phone
Fax
Email
Affiliate Corporations
Company FEIN Number (Federal Employer Identification Number)
Company SIC Number (Standard Industrial Code Number)
D&B Number (Duns & Bradstreet)
MDOT Prequalification Number
MDOT Prequalification Rating
Company Type
Is your company a supplier or subcontractor?
If Subcontractor, what type? (Check all that apply)
Date of Incorporation
in the State of
 
Certifications
DBEMBEWBE
SBECity of Detroit CertifiedWayne County Certified
Labor
Union Non-Union   

Services Provided:
( Hold down Ctrl while clicking multiple selections)

List Locals
   
Equal Opportunity Employer:
YesNo   
Percent Self Performed
Total Number of Employees: Full Time , Part Time , Leased/Contract
Range of Contract $ to $
Bonding Capacity
 $
 
Bonding Company
 
Insurance Company
 
General Liability Expiration Date
Automobile Liability Expiration Date
Workers Comp Expiration Date
Years with current surety provider:
References
Company
Contact
Telephone Number
Has your organization ever failed to complete any work awarded to it?
YesNo   
If yes, please explain
Are there any judgments, claims, arbitration, proceedings or suits pending or outstanding against your organization or its officers?
YesNo   
If yes, please explain
Has your orgainization ever filed Chapter 11 or Chapter 7 proceedings?
YesNo   
If yes, please explain
       

Safety Information:

Required Experience Modification Rating (EMR) Information (Past Three Years):
Contact your insurance carrier for this information if you do not know it.

Year
Rate
Year
Rate
Year
Rate
   
 
Current Lost Day Rate
As of:
   
 
Current Incident Rate
As of
   
 
Does your organization have a Formal Safety Program
YesNo   

Has your organization received any OSHA citations in the past three (3) years?
YesNo   
If yes, please explain

Has your organization had a fatality in the past three (3) years?
YesNo   
If yes, please explain
Completed By
 
Title
 
Date
 
     

©2006 Carlo Companies