Subcontractor Prequalification Application Subcontractor Prequalification Application Step 1 of 6 16% General Company InformationSubcontractor Name*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*FaxWebsite When was your company established?* MM DD YYYY Employees are*UnionNon-union (Open shop)List Union Locals*Select any/all that apply* DBE company MBE company WBE company None of the above Contact InformationContact Name* First Last Contact Title*Email* Save and Continue Later Company DetailsHas company operated under any other name(s) in the last five years?*YesNoList the other name(s) has this company used in the last five years*List the type(s) of work your company performs (including the number of years performed for each work type)*Add a row for each type of work. Click the plus sign to add a new row. Work TypeYears Performed List the states in which your company is licensed to work*Click the plus sign to add a row for each state.StateLicense Number Geographic areas served*Is company DOT prequalified?*YesNoSelect the state(s) in which your company is DOT prequalified*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingOrganizational StructureOwner or CEO* First Last CFO or Controller* First Last Safety Contact* First Last Estimating Contact* First Last Contracts Contact* First Last Other pertinent contact(s)Use the plus sign to add a row for each person listedFirstLastTitle Save and Continue Later Financial InformationHas your company ever filed for bankruptcy?*YesNoHas your company ever defaulted on a construction contract?*YesNoAre there any pending judgments, claims, or suits outstanding against your company?*YesNoExplain pending judgments, claims, or suits*Please select the financial statements you will provide*AuditedReviewedCompiled or Internally PreparedUpload your balance sheet and income statement*Include latest internally prepared financial statements AND latest audited comparative financial statements Drop files here or Upload your balance sheet and income statement*Include latest internally prepared financial statements AND latest reviewed comparitive financial statements Drop files here or Upload your balance sheet and income statement*Include latest internally prepared financial statements AND latest compiled or internally prepared financial statements covering the last two years Drop files here or Annual Revenue2016 Revenue*2015 Revenue*2014 Revenue*Largest (highest value) project currently under contract*Current backlog (cost to complete)*Banking InformationName of Primary Banking Institution*Years with above Institution*Please enter a value between 0 and 99.Relationship Manager Name* First Last Relationship Manager Phone*Does your company maintain a line of credit?*YesNoCredit Limit*Amount of Credit Line Currently Available*BondingIs your organization bonded?*YesNoName of Surety*Single Project Limit*Aggregate Limit*InsuranceUpload your Certificate of Insurance*Certificate must reflect compliance with Insurance Requirement set forth in Attachment "B" of Exhibit A-Master Subcontract Agreement (sample agreement available in PDF format below the application). Save and Continue Later ReferencesPrimary Vendors*List names and contact information for three (3) of your organization's primary vendors.CompanyContact Person NameContact Phone Recent Clients*List names and contact information for three (3) of your organization's recently completed jobs.Customer/ProjectContact Person NameContact PhoneContract Value Save and Continue Later SafetyCurrent Experience Modification Rate (EMR)*2015 EMR*2014 EMR*Current Total Case Incident Rate (TCIR)*2015 TCIR*2014 TCIR*Have you had any serious OSHA or EPA violations in the last 5 years?*YesNoExplain OSHA/EPA violation(s)*What portion of your employees are certified in First Aid & CPR?*NoneMost SupervisorsAll SupervisorsAll Supervisors and Most EmployeesAll EmployeesWhat portion of your employees have their OSHA-10?*NoneMost SupervisorsAll SupervisorsAll Supervisors and Most EmployeesAll EmployeesWhat portion of your employees have their OSHA-30?*NoneMost SupervisorsAll SupervisorsAll Supervisors and Most EmployeesAll EmployeesDoes your company have a DOT Number?*YesNoCompany DOT Number*DOT Safety Rating*Does your company have a corporate safety plan?*YesNoUpload your Safety Plan*Additionally, please review JRE Safety Requirements in Attachment C of Exhibit A-Master Subcontract Agreement (sample agreement available in PDF format below the application).You've indicated your company does NOT have a corporate safety plan. Please explain.* Save and Continue Later Items for ReviewPlease make sure to review the following items, which are available for download below as a single PDF file. EXHIBIT A- Sample Master Subcontract Agreement (Which includes the following attachments) Attachment B- Insurance Requirements AND Attachment C- Safety Requirements Open Sample Master Subcontract Agreement Certification & AcknowledgmentSubcontractor certifies that all information provided herein and any references made by attachments, are true, correct and complete and accurately represent the past and current state of this company. Subcontractor also acknowledges that all information supplied will be used for the purpose of determining the Subcontractor’s Prequalification approval status, including, but not limited to contacting of references listed and verification of information provided. Further, Subcontractor understands that upon review of all information supplied herein, the Subcontractor may be required to supply additional information to J. Ranck Electric, Inc., in order to make such final determination of Subcontractor’s Prequalification approval status. Subcontractor will provide notification to J. Ranck Electric, Inc. of any significant changes in information supplied that may occur after submission of the application, but before final approval.Your full name and title*Check box to agree* I agree to the above certification & acknowledgment Save and Continue Later Sample Master Subcontract Agreement (PDF) If you have questions about prequalification or this application, contact our office or submit questions online.