Subcontractor Qualification Form

Section I - Company Information

Company Name:
Address:
City:	State: Zip:

Main Phone Number:
Main Fax Number:

Entity Type
	Corporation	Tax ID #
	Partnership	Years in Business:
	Individual/Sole Proprietorship *	No. of Employees:
	Other
	* See Section VI –#5 Additional Documentation for Individual/Sole Proprietorship

Type(s) of Work Performed

Select any/all that apply to the business:

MBE	WBE	DBE	Affirmative Action
Union	Non Union

Has your company ever failed to complete any work awarded to it? Yes No
If yes, please explain:

Are there any judgments, claims, arbitration proceedings or suits pending or outstanding against your organization or its owners/officers? Yes No
If yes, please explain:

Section II – Bank & Trade References

Bank Name:
Bank Contact:
Bank Contact Phone:
Contact Email:

Please list contact information for the 3 suppliers that you use most frequently.
Materials/Supplier Name	Contact Name	Contact Phone & Email

Please list contact information for 3 projects completed within the past year.
Company & Project Name	Contact Name	Contact Phone & Email

Section III – Bonding & Insurance

Bonding Company Name / Address
Bonding Limits
Bonding Contact Name/Phone

Section IV – Safety

Has your company been cited by OSHA within the past 4 years?
Yes No
If yes, for what?

Does your company hold documented safety meetings? Yes No
If yes, how often?

3) Do you conduct on-jobsite safety inspections? Yes No
If yes, how often?

Section V – Company Contact / Bid Information

Do you have the ability to print large format documents (plans) in-house?
Yes No

Do you use web-based project management tools? Yes No
If yes, which one?

Which person(s) in your company should receive our invitations to bid?

Primary Contact:		Secondary Contact:
Name:		Name:
Direct Phone:		Direct Phone:
Cell Phone:		Cell Phone:
Email:		Email:
Fax Number:		Fax Number:
Scope:		Scope:
Method to receive bid invites?	Email Fax	Method to receive bid invites?	Email Fax

Section VI – Additional Information

In addition to this completed form, please provide the following documents:
1) W-9 form (Request for Taxpayer Identification Number and Certification).
2) Certificate of Liability Insurance issued by your carrier showing your current coverage(s), policy numbers, effective dates and limits.
3) A dated & signed letter from your worker’s compensation carrier verifying your EMR (Experience Modification Rating) for the past 3 years. Companies that do not have an EMR must provide a signed & dated letter from an officer of your company stating that they are self-insured.
4) Additional documentation is required for Individuals and Sole Proprietorships. These entities are subject to Minnesota Statute Section 290.92, Subd. 31 requiring deduction and withholding of 2% of the payment as Minnesota income tax withholding. In addition, these individuals must provide a copy of a completed Independent Contractor Exemption Certificate (application is available on our website or at the website listed below). No project work will be awarded to individuals who do not provide this documentation. For more information, see www.taxes.state.mn.us/taxes.

I have read and agree to the terms of the Welsh Construction Standard Subcontractor Agreement as posted on www.welshconstruct.com. Yes No

Your Name:
Title:
Phone:
Fax:
Email:

Download and complete W-9 Form. Fax the completed W-9 form to 952-842-7825
Download and complete Independent Contractor application . Fax to 952-842-7825

If you have any questions about the form or required documents please contact;

Sarah Pieper
Email: spieper@welshco.com
Phone: (952) 897-7825