Subcontractor Prequalification Form

Company Name *

NOTE: As it appears on your W9 and should appear on contracts/checks

Company Address

Street *

City *

State *

Zip *

Website

Accounting Information

Accounting Contact *

Main Phone *

Email Address *

Trades Performed *

Subcontractor Diversity

Minority Owned/MBE *

Yes

No

Safety:

Has your company had any OSHA citations, violations or fines in the last (3) years? *

Yes

No

Explain:

EMR Rating: *

Experience:

Please list below your three (3) largest most recently completed projects.

Contractor *

Date Completed *

Contact *

Phone Number *

Project *

Contract Amount $ *

City *

State *

Number of jobs completed with this contractor *

Add Remove

Banking Information

Great News! Electronic payments are now available! Get your payments quicker when you enroll in ACH payments. You will not have to drive to our office, wait for the mail, or have to endorse a paper check. You’ll be notified by e-mail when your payment is sent and your bank account will electronically receive our payment in 1-2 business days. Payment advices (invoice detail with corresponding dollar amounts) are emailed to vendors with each payment

Preferred Method of Payment *

ACH Information

Vendor Name: *

Contact Name *

Contact Phone Number: *

Primary Email *

Secondary Email *

Bank Name *

Bank Address *

Bank Address

Street

Street 2

City

State/Province

Zip/Postal

Bank Phone Number *

Name On Bank Account *

Bank Routing Number (9 Digits) *

Bank Account Number *

Select One *

Checking

Savings

Authorized Signature *

Authorized Signer Title *

Authorized Signer Name *

Date *

Mailed Check

Remittance Address *

Remittance Address

City

State/Province

Zip/Postal

W-9

1. Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. *

2. Business Name/disregarded entity name if different from above

3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes *

Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner. *

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):

Exempt payee code (if any)

Exemption from FATCA reporting code (if any)

5 Address (number, street, and apt. or suite no.) See instructions. *

6 City, state, and ZIP code *

7 List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter.

Social Security Number Or

Employer identification number

Part II Certification

Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.

Signature of U.S. person *

Date *

Certificate of Insurance Upload

File Upload

Drop a file here or click to upload Choose File

Maximum upload size: 516MB

Prequalification

Company Address

Accounting Information

Subcontractor Diversity

Safety:

Experience:

Banking Information

ACH Information

Mailed Check

W-9

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):

Part I Taxpayer Identification Number (TIN)

Part II Certification

Certificate of Insurance Upload

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