Business Type *

select one

Corporation

Partnership

Limited Liability Company

Sole Proprietor

Indicate your NC Statewide Uniform Certification *

See doa.nc.gov/hub/swuc.htm for more information

MBE

HBE

AABE

WBE

SDB

DBE

N/A

Option 8

Is your firm registered and in good standing with the Department of the Secretary of State to conduct business in the State of North Carolina? *

Yes

No

Is your firm owned or controlled by a parent or any other organization? *

Yes

No

Confirm that your company can demonstrate compliance with insurance coverages which meet or exceed the minimum requirements of the State Construction Manual OC-15 Article 34 *

See ncadmin.nc.gov/businesses/construction/forms-documents for more information

Yes

No

Has your company maintained an EMR of 1.0 or lower for the past five (5) years? *

Yes

No

Does your company have a written 'Safety Program and Plan' in compliance with current OSHA requirements for your scope(s) of work? *

Yes

No

Does your company provide weekly training and safety inspections? *

Yes

No

Is your business required to have a trade license or certification? *

Yes

No

Has your company filed any claims against a GC, PM or Owner within the past five (5) years, whether resolved or pending? *

Yes

No

Has your company been involved in any judgments, arbitration or mediation proceedings, or suits within the last five (5) years, whether resolved or still pending? *

Yes

No

20a. Has your company ever failed to complete work awarded? *

Yes

No

20b. Have you ever paid liquidated damages on any project? *

Yes

No

20c. Has your bonding company had to take any of the following in the last ten (10) years: Project technical support, Payments to vendors, Supplement work on a contract, or complete a contract for your compnay? *

Yes

No

20d. Has a Bid Bond ever been collected upon on a project your company bid in the past five (5) years? *

Yes

No

20e. Has your present company, its officers, owners, or agents ever been convicted of charges relating to conflicts or interest, bribery or bid-rigging? *

Yes

No

20f. Has your present company , its officers, owners, or agents ever been barred form bidding public work in North Carolina? *

Yes

No

Name of the person completing this form *

First Name

Last Name

As the person completing this form you confirm that you are an authorized person to represent the above listed company? *

Yes

No

As an authorized person completing this form you confirm that all of the above information is answered truthfully and to the best of your ability? *

Yes

No