MWBE Form

Step 1 of 4

legal_name_of_company*

contact_person*

title*

Address

street_address*

city*

State

State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District 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
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific

state*

zip_code*

phone*

website

If name has changed, how long have you been doing Business under your current name?

current_company_name*

Type of Company

Type of Company
Supplier
Vendor
Construction
Professional Services

type_of_company*

Please describe services/goods your company provides

good_or_services_description

How many owners does the company have?

Please select

Please select
1
2
3

company_owners

Please enter information for Owner 1

owner_one_name

owner_one_position

owner_one_years_experience

owner_one_years_with_company

owner_one_percent_owned

Please enter information for Owner 2

owner_two_name

owner_two_position

owner_one_years_experience

owner_two_years_with_company

owner_two_percent_owned

Please enter information for Owner 3

owner_three_name

owner_three_position

owner_three_years_experience

owner_three_years_with_company

owner_three_percent_owned

If interested in specific project, please indicate which one(s)

project_interested_in*

Business Certification

Select appropriate classification(s)*

business_certification_kinds*

business_certification_file_upload

Drop files here or click to select

Labor Force

Union:

Please select

Please select
Yes
No
N/A

union*

Financial Information: Gross Revenue

calendar_year_2016*

calendar_year_2017*

calendar_year_2018*

expected_annual_volume_calendar_year_2019*

Bank Information

bank_name*

line_of_credit_amount*

List 3 Largest Projects Recently Completed (within the past 3 years):

Project # 1

project_one_name*

project_one_gc_company_name*

project_one_contact_name_and_phone*

project_one_contract_amount_and_date_completed*

project_one_trade_or_services_performed*

Project # 2

project_two_name*

project_two_gc_company_name*

project_two_contact_name_and_phone*

project_two_contract_amount_and_date_completed*

project_two_trade_or_services_performed*

Project # 3

project_three_name*

project_three_gc_company_name*

project_three_contact_name_and_phone*

project_three_contract_amount_and_date_completed*

project_three_trade_or_services_performed*

List 3 References:

Reference # 1

reference_one_name_or_company*

reference_one_phone

Reference # 2

reference_two_name_or_company*

reference_two_phone*

Reference # 3

reference_three_name_or_company*

reference_three_phone*

Bonding Information

Has the firm received a bond?

N/A

received-bond*

Bond Information

bond_surety_company

bond_total_bondable_amount

bond_contact

bond_current_bonding_amount_in_effect

bond_phone

bond_single_project_bond_limit

bond_bonding_agent

bond_average_bond_rate

bond_date_of_last_bond_issued

Insurance Information

insurance_company*

insurance_company_contact_name_and_phone*

General Information

1. Have any of the officers or principals of your firm been officers or principals in another firm that closed operations in the past three (3) years? If yes, explain.

general_info1*

2. Are there any claims, arbitration proceedings, or suits pending or outstanding against your firm or its officers or principals? If yes, explain.

general_info2*

3. Does your firm have any outstanding judgments? If yes, explain.

general_info3*

4. Has your firm filed any lawsuits or requested arbitration or mediation with regard to construction contracts within the past three (3) years? If yes, explain.

general_info4*

5. Has your firm either failed to complete any work contracted for, or been terminated for default under any construction contract within the past three (3) years? If yes, explain.

general_info5*

6. List any litigation brought against your firm in the past three (3) years asserting that you failed to make payments to anyone.

general_info6*

7. Has your firm been sighted or fined for safety violations in the last three (3) years? If yes, explain

general_info7*

I certify that this information is true & complete.

certified_by_name*

certified_by_title*

certified_by_signature_initials*

certified_by_date*

D | A | C | K

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