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Prequalification Form

Date*

Federal ID #*

Contact Name*

Job Title*

Company Name*

Street Address*

City*

State/Region*

Postal Code*

Phone number*

Fax Number

Email*

Business Type

List all trade work your company performs:*

Number of Employees (Office)

Number of Employees (Shop)

Number of Employees (Field)

Number of Employees (Total)

Is your company directly or indirectly signatory to any labor union agreements?*

Financial

Last Year Annual Sales Volume

Two Years Previous Annual Sales Volume

Three Years Previous Annual Sales Volume

Largest Single Contract Awarded in the Last Three Years

Contract Award Description

Current Backlog

Upload Financial StatementsPlease attach last two years of financial statements. Include balance sheets, income statements, and opinion letter from Accountant. If this information is not available, please substitute the last two years of tax returns.

Banking

Primary Bank*

Bank Street Address*

Bank City*

Bank State*

Bank Postal Code*

Bank Contact Name*

Bank Phone Number*

Bank Contact Email Address

Does your company have a line of credit?*

Secured
Unsecured
None

I give my bank contact person listed above, permission to discuss my general banking relationship with Howard Immel, Inc. as it relates to my company securing a subcontract with them.

Is your company listed with Dun & Bradstreet?*

Is your company bondable?*

Legal

Has your company failed to complete any work awarded to them?*

Are there any Judgements, Claims, Arbitration, Proceedings, or Suits pending or outstanding against your organization or its officers?*

Has your company filed any lawsuits or requested mediation, arbitration, or litigation with regard to construction contracts in the past five years?*

Has your company or its principals ever filed for bankruptcy?*

If you answered yes to any Legal questions, please provide an explanation:

Safety

Experience Modification Rate from Last Year:

Experience Modification Rate from First Prior Year:

Experience Modification Rate from Second Prior Year:

Number of Fatalities - Last Year:

Number of Fatalities - First Year Prior:

Number of Fatalities - Second Year Prior:

Have you had any OSHA Inspections in the past five years?*

Does your company employ a full-time safety representative?*

Does your company conduct weekly, documented safety audits?*

Will your company provide us with SDS sheets and a safety manual for your company prior to work?*

Does your company agree to meet Immel's Safety Regulations?*

Insurance

Please attach a current Certificate of Insurance*

References

Three client references are required. Please provide the following information:

Reference Client Company Name*

Reference Client Contact Name*

Reference Client Contact Phone Number

Reference Client Contact Email

Reference Client Company Name 2*

Reference Client Contact Name 2*

Reference Client Contact Phone Number 2

Reference Client Contact Email 2

Reference Client Company Name 3*

Reference Client Contact Name 3*

Reference Client Contact Phone Number 3

Reference Client Contact Email 3

Similar Project Experience

Project Name

Contract Amount

Owner/General Contractor

Project Contact Name/Phone Number

Project Name 2

Contract Amount 2

Owner/General Contractor 2

Project Contact Name/Phone Number 2

Project Name 3

Contract Amount 3

Owner/General Contractor 3

Project Contact Name/Phone Number 3

Project Name 4

Contract Amount 4

Owner/General Contractor 4

Project Contact Name/Phone Number 4

Project Name 5

Contract Amount 5

Owner/General Contractor 5

Project Contact Name/Phone Number 5

Signature

The undersigned certifies that the information provided herein is true and sufficiently complete so as to not be misleading.

Signature*

Title*

Signature Date*

Howard Immel Inc.
2601 Development Drive
Green Bay, WI 54311

Operations Center
1820 Radisson Street
Green Bay, WI 54302

Phone: 920-468-8208

Fax: 920-468-7160

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