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Company Name
Company Address
City
State ILALAKASAZARCACOCTDEDCFMFLGAGUHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVIVAWAWVWIWY
Zip
Name
Title/Position
Email
Office Phone
Mobile Phone
Office Fax
How many years has your company been in business?
What is your average yearly revenue over the past three years?
What is your average project size ($/Project)
What is the dollar value of the largest project successfully completed by your company
Can you provide a bond? YesNo If yes, up to what dollar amount?
Has your company ever failed to complete any work awarded in the past five years? YesNo If yes, please explain
Are there any pending or outstanding claims, arbitrations, or lawsuits against your company? YesNo If yes, please explain
What work categories does your company perform?
Is your company experienced with prevailing wage projects? YesNo
Is your company union? YesNo If yes, please list the unions with which your company is affiliated
What is the average size of your field work force?
Does your company qualify with any of the following? Small BusinessSmall Disadvantged BusinessMBEWBEHUBZoneVeteran Owned Small business
Certified by:
Company Contact Contact Phone
Are you willing to travel for projects outside the Chicago and Chicagoland Market? YesNo
Project Contract Amount Project Type ---SelectTenant interiorService WorkMedicalPublic WorkConstruction ManagementResidentialDeveloper ServicesLeak FixBar/RestaurantThermal ImagingInstitutionalInsurance Work Work Performed
Project Contract Amount* Project Type ---Tenant interiorService WorkMedicalPublic WorkConstruction ManagementResidentialDeveloper ServicesLeak FixBar/RestaurantThermal ImagingInstitutionalInsurance Work Work Performed
Project Contract Amount Project Type ---Tenant interiorService WorkMedicalPublic WorkConstruction ManagementResidentialDeveloper ServicesLeak FixBar/RestaurantThermal ImagingInstitutionalInsurance Work Work Performed
Present EMR is
Employee hours worked last year (2012):
State of origin: ILALAKASAZARCACOCTDEDCFMFLGAGUHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVIVAWAWVWIWY
Have You received any regulatory (EPA, OSHA,Etc) Citations in the last three years? YesNo If yes, please attach copies using the file upload section at the end of this form
Do you have a written safety and health program? YesNo
Do you have a written Hazard Communication Program? YesNo
Do your employees read, write and understand English as such that they can perform their job tasks without an interpreter? YesNo
Do you have personnel trained to perform CPR & First aid? YesNo
Do you have safety and health orientation for new hires and newly hired or promoted supervisors? YesNo
Have your employees received required health and safety training and retraining? YesNo
Do you hold site safety and health meetings for: Field supervisorsEmployeesNew HiresSubcontractors
Are Safety and health meeting documented: YesNo
Do you conduct safety & health inspections? YesNo
Do you conduct safety & health program audits? YesNo
Are corrections of deficiencies documented? YesNo
Additional Comments
File Upload: Please attach any additional information, qualifications, promotional materials etc. which you feel would be of interest to SYNERGY. Any additional information is NOT required but will be reviewed (PDF, Word Doc, JPG files accepted).
I verify that the information provided above is accurate.
