Subcontractors and Vendors

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Subcontractors and Vendors

Pellicano Construction requests that all subcontractors and vendors complete the qualification form:

GENERAL INFORMATION
Select One of the Following*
- SOLE PROPREITORSHIP
- PARTNERSHIP
- CORPORATION
- SUB-S CORP.
NAME OF FIRM*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
YEAR FIRM BEGAN OPERATION
TOLL FREE NUMBER
Corporate Officers- Partners-Proprietorship
NAME
AGE
POSITION
YEARS W/ FIRM IN THIS POSITION
% OF OWNERSHIP
Please enter a number from 0 to 100.
NAME
AGE
POSITION
YEARS W/ FIRM IN THIS POSITION
% OF OWNERSHIP
Please enter a number from 0 to 100.
NAME
AGE
POSITION
YEARS W/ FIRM IN THIS POSITION
% OF OWNERSHIP
Please enter a number from 0 to 100.
Type of work your firm specializes in:
List the geographic areas (States) where your firm is licensed to do business:
Estimating Contact:
Name
Email
Phone
President or Local Manager:
Name
Email
Phone
Does your organization have in-house design/engineering capabilities?
- Yes
- No
If so, does your firm carry professional Liability (errors & omissions) Insurance?
- Yes
- No
Would you be willing to provide current financial statements when requested?
- Yes
- No
DIVERSITY
Certified Minority Business Enterprise?
- Yes
- No
Minority Owned
Woman Owned
Other
CERTIFICATION DATE
MM slash DD slash YYYY
CERTIFICATION CITY
CERTIFICATION STATE
BONDING INFORMATION
Name of Bonding Company (not agent)
Bonding Agent
NAME
ADDRESS
PHONE
BOND RATE
LARGEST BONDED JOB
BONDING CAPACITY: SINGLE:$
BONDING CAPACITY: AGGREGATE:$
ESTIMATED UNUSED BONDING CAPACITY
LARGEST ANNUAL VOLUME AT ANY ONE TIME
YEAR
HISTORY/ JOB EXPERIENCE
Average Annual Volume
Largest Project Completed
Current Backlog
PROJECT REFERENCES
List below three (3) largest jobs compiled in the past three (3) years; including person to contact, phone number, contract amount and work performed:
JOB NAME
OWNER TO CONTACT
Phone
AMOUNT OF CONTRACT
WORK PERFORMED
JOB NAME
OWNER TO CONTACT
Phone
AMOUNT OF CONTRACT
WORK PERFORMED
JOB NAME
OWNER TO CONTACT
Phone
AMOUNT OF CONTRACT
WORK PERFORMED
INSURANCE INFORMATION
Experience Modification Rate (EMR):
Insurance Company Agency (G/L & Workers Compensation)
Name/Contact
Address
Street Address City State / Province / Region ZIP / Postal Code
Phone
Pellicano Construction is hereby authorized to investigate the references listed pertaining to performance and financial responsibility Signed on
MM slash DD slash YYYY
Name of Company
Signed By
Title

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FTP Site

Albany:

415 Pine Avenue, Suite 200
Albany, GA 31701
Phone (229) 883-6000
Fax (229) 883-4220

Athens:

540 Baxter Street, Suite A
Athens, GA 30605
Phone (770) 766-0076
Fax (770) 766-0116

Atlanta:

990 Hammond Drive, NE
Bldg. 1, Suite 825
Atlanta, GA 30328
Phone (770) 542-2400
Fax (770) 542-2405

Macon:

153 Gateway Drive, Suite B
Macon, GA 31210
Phone (478) 254-2772
Fax (478) 254-3532

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Subcontractors and Vendors

GENERAL INFORMATION

Corporate Officers- Partners-Proprietorship

Estimating Contact:

President or Local Manager:

DIVERSITY

BONDING INFORMATION

Bonding Agent

LARGEST BONDED JOB

HISTORY/ JOB EXPERIENCE

PROJECT REFERENCES

INSURANCE INFORMATION

Insurance Company Agency (G/L & Workers Compensation)