SUBCONTRACTOR PRE-QUALIFICATION FORM

Non Disclosure Information

In consideration of the Prequalification Applicant’s willingness to disclose its Confidential Information to the William Chares Companies, and the William Charles Companies’ disclosure of Confidential Information related to construction projects the party receiving Confidential Information (the “Recipient”) agrees to maintain the Confidential Information in confidence and not to disclose it to anyone else, nor use it for Recipient’s own benefit or for the benefit of others without the Disclosing party’s prior written consent. Recipient agrees to limit the disclosure of the Confidential Information to those internal persons and outside advisors who have a need to know such Confidential Information and only to such of those persons who agree to be bound by the terms of this Non Disclosure Restriction. Recipient indemnifies the Disclosing Party for any misuse of the Confidential Information by any person or entity to whom Recipient has disclosed the Confidential Information.

For the purposes of this Restriction, Confidential Information shall include, but not be limited to, technical data (e.g. computer software, drawings, processes, hardware, firmware), business and financial information, correspondence, written or oral representations, memoranda, reports, records, or other such conveyance of information which is proprietary and held confidential by the disclosing party and identified in the Prequalification form or identified by the Disclosing Party. However, Confidential Information shall not include any information: (a) which was known or used by Recipient prior to the date of such disclosure as evidenced by Recipient’s written records; or, (b) which is in the public domain; or, (c) which has legally come into Recipient’s possession through channels independent of the Disclosing Party; or, (d) which is required by law or legal process to be disclosed.

The term of this Restriction shall commence on the date the Prequalification Applicant submits its Prequalification to the William Charles Companies and shall be in full force and effect for a period of eighteen (18) Months. If the Prequalification applicant is not selected to perform work for the William Charles Companies this Confidentiality Restriction shall survive and shall be binding upon the parties for a period of two years from the date of disclosure of any Confidential Information.

Any and all documents produced or delivered by one party to the other party shall remain the property of the Disclosing Party, and all such documents and all copies thereof shall be promptly returned to the delivering party upon demand. If the Recipient is served with a subpoena or other document or directive containing the force of law requiring disclosure of Confidential Information, the Recipient shall immediately disclose the subpoena or other document or directive to the Disclosing Party so that the Disclosing Party shall have sufficient opportunity to, if it so chooses, contest the subpoena or other document or directive.

Company Contact Information

Please select the company for which you wish to qualify *

William Charles Construction

Ragnar Benson Construction

ACC West Coast

If applicable, please specify the project for which you wish to qualify.

Today's Date * +

Name of Company *

Contact Title *

Contact First Name *

Contact Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Fax Number *

Email Address *

Web Site

Company History

Please select type of business. *

Union

Non - Union

Please select company type. *

Date Founded * +

Under Present Management Since: * +

Has Your Firm Done Business Under A Different Name? *

Yes

No

If Yes, What Name If Yes, What Name

Has Your Firm Ever Failed To Complete Any Work Awarded Within The Last 5 Years *

Yes

No

If Yes, Please Explain

Are you qualified as a contractor under the U.S. government System for Award Management (SAM) process? If so, please provide any certification or registration number applicable to www.sam.gov. *

No

Yes Yes

Have you ever been debarred or suspended from qualification under the System for Award Management (SAM) process? If so, please explain details including date, reason, terms of suspension, and the date of any reinstatement. *

No

Yes Yes

Has Your Current Firm Or Any Predecessor Organization Been Involved In Any Litigation, Arbitration or Legal Dispute With An Owner, Architect, Or General Contractor Within The Last 5 Years? *

Yes

No

If Yes, Please attach Explanation

Annual Dollar Volume

	Dollar Amount
2023	Dollar Amount
2022	Dollar Amount
2021	Dollar Amount
2020	Dollar Amount
2019	Dollar Amount
2018	Dollar Amount

Name Of Company Officers, Principals, Partners, Or Owners (Please Include Name and Title)

	Name	Title
Name 1	Name	Title
Name 2	Name	Title
Name 3	Name	Title
Name 4	Name	Title
Name 5	Name	Title

Current # Of Employees

	#
Office	#
Field	#

Work History

Please Attach A List of Current Projects, Including Contract Amount, Expected Completion Date, Architect Name, General Contractor Name, Project Manager Name, And Phone Number.

Bidding Information

Type Of Projects Your Company Specializes In (Please Check All Applicable Types) *

Preferred Job Cost Range *

Please select all states where your company is willing and able to work. *

If Region Specific, Please Descripe

Please List Work Types Normally Performed By Your Own Forces

	Work Type
1.	Work Type
2.	Work Type
3.	Work Type
4.	Work Type
5.	Work Type
6.	Work Type
7.	Work Type

Please List Work Usually Subcontracted Out To Others

	Work Type
1.	Work Type
2.	Work Type
3.	Work Type
4.	Work Type
5.	Work Type

Safety

Does Your Company Have: (Please Check All Applicable Items) *

A Company Wide Written Safety Program

A Qualified Full Time Safety Director or Safety Professional

A Pre-Hire Drug Testing Program

A Pre-Hire Physical Examination

Documented, Regularly Scheduled Safety Meetings for Employees

A Return to Work/Light Duty Program

A Policy to Review the Safety Management System of your Sub-Contractors

All of the Above

Has Your Company Implemented 100% Fall Protection at 6 Feet and Above *

Yes

No

Has Your Company Ever Received A Willful OSHA Citation? *

Yes

No

If Yes, Please Explain

Please List your Firms Experience Modification Rate (EMR)

	EMR	-
2023	EMR	-
2022	EMR	-
2021	EMR	-
2020	EMR	-
2019	EMR	-
2018	EMR	-

Please List your Firms Recordable Incident Rate (RIR)

	RIR
2023	RIR
2022	RIR
2021	RIR
2020	RIR
2019	RIR
2018	RIR
-	RIR

Please List your Firms Number of OSHA Recordables

	OSHA
2023	OSHA
2022	OSHA
2021	OSHA
2020	OSHA
2019	OSHA
2018	OSHA

If EMR is greater than 0.90 please attach OSHA Logs / incident reports for the past 2 years.

Bonding

Surety Company Name *

Surety Broker Name *

Surety Company Address

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Bonding Capacity Per Job ($) *

Bonding Capacity (Aggregate $) *

Insurance

Insurance Carrier name *

Insurance Agent Name

Insurance Carrier Address

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Please Attach A Sample Certificate of Insurance

Financial

Please attach their most recent financial report/audit

D-U-N-S #

Please enter the name of your banking institution

Please Provide Your Banking Instutition Contact Information

First Name

Last Name

Street Address

Address Line 2

City

State

Zip Code

Phone Number

Email Address

Have you ever been debarred or suspended by any government agency?

Yes

No

If Yes, please identify the agency and reason for debarment/suspension.

If Yes, Please provide the date the company was reinstated +

If Yes, please upload proof of reinstatement

EEO

Do you have a designated EEO Officer? *

Yes

No

EEO Officer Name

EEO Officer Phone #

Does your company utilize E-Verify to confirm that their employees are legally permitted to work in the U *

Yes

No

What good faith efforts do you take to recruit minority and women employees? Please Describe.

What percentage of your workforce is classified by the Department of Labor as a recognized minority?

What percentage of your workforce is female?

Disadvantaged, Minority, Woman, Small & Veteran Business Enterprise (DBE/MBE/WBE/SBE/VBE)

49 CFR Part 26, stipulates that every DBE must perform a Commercially Useful Function, this means DBEs must be responsible for the management and supervision of the entire scope of work on a particular contract, own their equipment, pay their employee and show independency from a non-DBE contractor. Non - DBE Contractors planning to use DBEs must comply with provision 49 CFR Part 26 which regulates DBE participation on public contracts.

Is Your Firm Certified As Any of The Following (Please Check All That Apply) *

Is the company qualified by any agency to perform work as Disadvantaged, Minority, Woman, Small or Veteran Business Enterprise (DBE/MBE/WBE/SBE/VBE)? *

Yes

No

If yes, Please list the agencies below.

In which NACIS or UCP codes are you certified as a DBE / VBE?

	NAICS/UCP Code	Authorizing Agency
1	NAICS/UCP Code	Authorizing Agency
2	NAICS/UCP Code	Authorizing Agency
3	NAICS/UCP Code	Authorizing Agency
4	NAICS/UCP Code	Authorizing Agency
5	NAICS/UCP Code	Authorizing Agency
6	NAICS/UCP Code	Authorizing Agency

Please attach a PDF of your most recent DBE/MBE/WBE /VBE Certification, “No Change Affidavit Approval” or "Continued DBE Eligibility Affidavit", etc.

DBE / VBE Certification

Additional DBE / VBE Information

Demolition	Clearing and Grubbing	Erosion Control
Earthwork	Rock Excavation	Soil Stabilization
Aggregate Base	Asphalt Paving	Concrete Paving
Roller Compacted Concrete Paving	Trackwork	Structural Concrete
Piling	Shoring	Bridge Construction
Retaining Walls	Compressed Air Systems	Industrial Waste Piping
Fueling Systems	Storage Tanks	Storm Drainage
Potable Water and Fire Distribution Piping	Sewer Piping	Jacking and Boring
Site & Roadway Electric	Fencing & Guardrail	Landscaping
Building Construction	Underdrain	Sawing
Concrete Flatwork and Curb	Traffic Control	Rotomill
Testing	Pavement Marking	Signs
Construction Surveying	Wick Drains	Painting and Coatings
Other Other

$0 - $500,000	$500,000-$1,000,000
$1,000,000-$5,000,000	$5,000,000-$10,000,000
$10,000,000-$15,000,000	$15,000,000-$20,000,000
Over 20 Million

Alabama	Alaska	Arizona	Arkansas	California
Colorado	Connecticut	Delaware	District of Columbia	Florida
Georgia	Hawaii	Idaho	Illinois	Indiana
Iowa	Kansas	Kentucky	Lousiana	Maine
Maryland	Massachusetts	Michigan	Minnesota	Mississippi
Missouri	Montana	Nebraska	Nevada	New Hampshire
New Jersy	New Mexico	New York	North Carolina	North Dakota
Ohio	Oklahoma	Oregon	Pennsylvania	Rhode Island
South Carolina	South Dakota	Tennessee	Texas	Utah
Vermont	Virginia	Washington	West Virginia	Wisconsin
Wyoming