Legal company name:

Federal tax ID number:

Mailing Address



City:


State:
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Estimator/Contact Name:

Business Phone:

Business Fax:

Business Email:

Business Website:

Company Established (month / year):

Form of Business:
Sole Proprietorship Partnership Corporation

Special Certifications: (Check all that apply):
MBE WBE DBE
LEDE EDGE LEED

If any are checked, which city awarded the certification:

Contractor License Type and Number:

Scope of work: (Please describe the type of work your company performs):

What size project are you comfortable performing? (State range in dollars)

References:

Project 1:

Company/Contractor

Contact Name

Phone

Project Name

Dollar Value of Contract

Completed on time
Yes No

Project 2:

Company/Contractor

Contact Name

Phone

Project Name

Dollar Value of Contract

Completed on time
Yes No

Project 3:

Company/Contractor

Contact Name

Phone

Project Name

Dollar Value of Contract

Completed on time
Yes No

We require all employees on our jobsites to be subjected to site drug and/or alcohol testing. Are you willing to comply?
Yes No

We require all employees to wear hard hats, work boots, safety glasses, long pants and shirts that cover the midriff, as well as other personal protective equipment as required on our jobsites at all times. Are you will to comply?
Yes No

Are you willing to comply with all OSHA, Owner, and C/K safety policies?
Yes No

Please indicate, by number, counties in which you are NOT willing to travel or work:

Please note: If this form is not filled out in its entirety, you will not be added to our solicitation system. This is for bidding purposes only. If being considered for a contract, we will request a more in depth qualification questionnaire. Thank you for your interest in Corna/Kokosing Construction Company.

I certify that the information in this questionnaire is correct and complete.
I agree