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Pre-qualified Vendor Application

Company Name
D/B/A

Category

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Address
Contact Person
Telephone Number
Fax Number
E-mail
Tax ID Number

Indicate whether company is a Individual Partnership Corporation Other (Please Specificy)
If other entity
Years Company has been in business
State of Incorporation or Registration
Number
Describe briefly below the areas of specialty during the last two (2) years

Attach local references for four of your company's largest contracts in the past six month to one year for the area(s) for which you are applying. Note - Weatherization vendors: multi-unit references are preferable. All references must include the below intems

Reference Name	Reference Number	Company Name	Project/Company Address	Contract Amount	Description of Services Provided

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Identify ownership and/or partnership of your company
Name Year of Ownership % Ownership

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Least each officer and director, shareholder,partner and co-venturer who either controls or owns directly or indirectly, a ten percent or greater interest in the company or who will actively participate int he performance by the company of the proposed contract
Name Address Telephone Position

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Is the company a Minority or Woman-Owned Business?** Yes No
If so, MWBE Certification number & Expiration Date
Is the company registered as such with the State of New York? If yes, please provide copy of Certificate Yes No
**The term "Minority Business" as used here means a small business concern: (a) which is at least 51% owned by one or more minorities or minority women, or in the case of any publicly owned business at least 51% of the stock is owned by one or more minorities or minority women; and (b) whose management and daily business operations are controlled by one or more of the minorities or minority women who own it

Please list all education and training that your require of your employees pertaining to your primary areas of specialty
Training Date

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Please list all Certifications/Licenses that your company requires for your primary areas of specialty
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Approximately how many jobs have you completed as a general contractor?
Are you an equal opportunity employer? Yes No
Are you authorized to do business in the State as well as locally, including all necessary business licenses? Yes No
Have you ever been a principal in a bankruptcy proceeding in New York State? Yes No
Do you currently have any outstanding judgements of Sheriff's liens posted against your company? Yes No
Are you willing to sign an affidavit of payments of debts, release of claim and warranty of workmanship regarding any proposed work accepted for ABC? Yes No
How many employees does your company employ?
Full-time
Part-time
Are you on the NYS Department of Labor's Employees Ineligible to Bid On or Be Awarded Any Public Work List? Yes No
If yes, what is the date of reinstatement?
Do you currently have access to bonding in New York State? Yes No
Can your company obtain coverage in the amounts required by ABC? Yes No
The undersigned swears that the foregoing statements are true and correct and include all material information necessary to identity and explain the operation of the applicant company as well as the ownership therof. Further, the undersigned agrees to provide to Action for a Better Community, Inc. complete and accurate information regarding actual work experience. If after filing this application there is any significant change in the information submitted, the undersigned agrees to inform ABC, Inc. of the changes directly. Misrepresentation of information will be grounds for termination of any contract which may be awarded under Federal or State Laws concerning false statements

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