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954-688-4577
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Pre-Qualification Form
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Subcontractors / Vendors
Subcontractors Pre-Qualification Form
Please complete the form below to pre-qualify with LeLack Construction.
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- required fields
Business Section
Legal Business Name
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Project, if applicable
Street Address
Street Address 2
City
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State 2
Select
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
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OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
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Zip
Zip 2
Principal Contact
Years in Business
Phone
Fax
Contact Email
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Company Website
Business Type
*
Sole Proprietor
Partnership
LLC/LLP
Corporation
Other
Have you failed to complete awarded work or been terminated for cause? Do you have any judgments, claims, arbitrations, suits or liens currently against your organization? Had any bankruptcies or reorganizations?
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Yes
No
*
If yes, please explain below:
Safety Section
Enter your Experience Modification Rate(EMR) for the last three years:
2007 (EMR) Rate
2006 (EMR) Rate
2005 (EMR) Rate
Number of OSHA Recordable incidents over the prior three years
(Data available at www.osha.gov)
Do you have a written safety program?
*
Yes
No
Project Information Section
Enter data from three most recent completed fiscal years:
Year
Max. Contract Value
Completed
Annual Company
Revenue
Current Year Company
Workload
List license numbers in jurisdictions in which you company is legally qualified to work:
State
License Number
Expiration
Insurance and Bonding Section
Do you currently carry, or can you obtain the following insurance coverage?
*
Worker's Compensation Statutory Maximum at Project Site Location
Yes
No
General Liability $1,000,000
Yes
No
Automobile Liability $1,000,000
Yes
No
Employer Liability $1,000,000
Yes
No
Bonding
Company
Total Bonding
Capacity $
Current Available
Bonding Capacity $
Reference Section
Project References (Within Last Three Years)
Project Name
Project Location (City, State)
Completion Date (MM/YY)
Your Firms Approximate Contract Amount
Project General
Contractor
GC Contact and Telephone Number
Briefly Describe Work Performed By Your Firm
Project Name
Project Location (City, State)
Completion Date (MM/YY)
Your Firms Approximate Contract Amount
Project General
Contractor
GC Contact and Telephone Number
Briefly Describe Work Performed By Your Firm
Project Name
Project Location (City, State)
Completion Date (MM/YY)
Your Firms Approximate Contract Amount
Project General
Contractor
GC Contact and Telephone Number
Briefly Describe Work Performed By Your Firm
Scope Of Work Section
(Scopes Of Work That Your Company Performs)
*
General Conditions
Site work
Concrete
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Wood & Plastics
Thermal & Moist. Protection
Doors & Windows
Finishes
Specialties
Equipment
Furnishing
Special Construction
Conveying Systems
Mechanical
Electrical
Security
Confidential Note:
The information supplied by the undersigned in this document is intended only for the use of LeLack Construction.
The undersigned certifies that the information provided herein is a clear and accurate representation of this organization. Information Supplied by:
Name
Title
Date
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Areas we Service:
Boca Raton, FL
Boynton Beach, FL
Deerfield Beach, FL
Delray Beach, FL
Fort Lauderdale, FL
Hollywood, FL
Lake Worth, FL
Miami, FL
Pompano Beach, FL
West Palm Beach, FL
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