GENERAL INFORMATION Name First Name Last Name Social Security/EIN# * Physical Address * State License/ID# * Date of Birth * MM DD YYYY Phone Number * Primary Email * Business Type * select one Corporation Partnership Limited Liability Company Sole Proprietor 1099 Individual Employee If you have selected above any option other than "Employee" confirm that you/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 YOUR STORY How did you hear about Black Card? * What are your strengths? * What are you weaknesses? * Are you willing to travel, using your personal vehicle, up to an 1 hour away from Black Card's home office? * Yes No Current number of hours worked weekly? * Current Salary? * $ Desired Salary? * $ Select Scope Performed * Painting/Coatings Drywall Installation Flooring Installation Consulting Agent Estimating Administrator 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 Do you currently have an OSHA 30 certification? If not, are you willing to obtain prior to working with Black Card? * This certification must be completed prior to your start date. 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 ADMINISTRATIVE ACTIONS Have you or your company filed any insurance claims against an Employer, GC, PM or Owner/Client within the past five (5) years, whether resolved or pending? * Yes No Have you or your company ever filed a Worker's Compensation claim against an Employer, GC, PM or Owner/Client within the past five (5) years, whether resolved or pending? * Yes No Have you or 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. Have you or your company ever failed to complete work awarded? * Yes No 20b. Have you or your company ever paid liquidated damages on any project? * Yes No 20c. Has your bonding company had to take any of the following actions in the last ten (10) years: Project technical support, Payments to vendors, Supplement work on a contract, or complete a contract for your company? * 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 from bidding public work in any state? * Yes No If yes to any of questions 20a. - 20f., please explain. * TEAM EXPERIENCE How many team members/employees do you currently manage? * Please list your company's 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 * 0-1 3-5 6-9 > 10 REFRENCES List relevant reference work no earlier than 3 years 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 Thank you for taking the time to submit your information. Your submission has been complete, you may exit your browser.
