COMPANY INFORMATION Company Name * Registered Name Physical Address * Phone Number * Owner(s) * Contact Name * Phone Number * Primary Email * Company website * BUSINESS TYPE Business Type * select one Corporation Partnership Limited Liability Company Sole Proprietor Indicate your NC Statewide Uniform Certification * See www.doa.nc.gov/hub/swuc.htm for more information MBE HBE AABE WBE SDB DBE N/A Is your firm registered 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 PAST PERFORMANCE Select Scope Performed * Painting/Coatings Drywall Installation Flooring Installation Largest project size for scope selected above * $ Number of projects currently working on * SAFETY List your company's Experience Modification Rate (EMR) for the past five (5) years. * present yr., last yr., yr. before, yr. before, yr. before 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 ADMINISTRATIVE ACTIONS 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 If yes to any of questions 20a. - 20f., please explain. * TEAM EXPERIENCE Please list your company assigned leader(s)/superintendent(s)? * Select the above leader(s)/superintendent(s) years of experience * 0-2 years 0-2 years 0-2 years 3-4 years 5-10 years > 10 years Select total number of skilled tradesmen within your company * 3-5 6-9 > 10 Reference No. 1 Project Name * Project No. 1 Scope Performed * Project No. 1 Project Completion Date * Project No. 1 GC/Owner Contact * project No. 1 GC/Owner Phone Number * Project No. 1 Project Dollar Amount * Project No. 1 $ Reference No. 2 Project Name * Project No. 2 Scope Performed * Project No. 2 Project Completion Date * Project No. 2 GC/Owner Contact * Project No. 2 GC/Owner Phone Number * Project No. 2 Project Dollar Amount * Project No. 2 $ Reference No. 3 Project Name * Project No. 3 Scope Performed * Project No. 3 Project Completion Date * Project No. 3 GC/Owner Contact * Project No. 3 GC/Owner Phone Number * Project No. 3 Project Dollar Amount * Project No. 3 $ 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 To complete the registration process please forward your company’s certificate of insurance and a completed W9 to our office at contact@blackcardesque.comIf a W9 form is needed please contact us at the email address above and we will provide one.PLEASE NOTE THAT BOTH OF THE FORMS ABOVE ARE NEEDED TO COMPLETE REGISTRATION.Thank you for taking the time to register with Black Card! We will be in touch shortly.
