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Pre-qualified Vendor Application


©2000-2012  Action for a Better Community, Inc.
550 E. Main Street  |  Rochester, NY  14604
(585) 325-5116  |  (585) 325-9108 - fax

  1. [Add]

  2. Individual Partnership Corporation Other (Please Specificy)

  3. 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
  4. Reference Name Reference Number Company Name Project/Company Address Contract Amount Description of Services Provided
  5. Identify ownership and/or partnership of your company
  6. Name Year of Ownership % Ownership
  7. 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
  8. Name Address Telephone Position
  9. Yes No
  10. Yes No
  11. **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

  12. Please list all education and training that your require of your employees pertaining to your primary areas of specialty
  13. Training Date
  14. Please list all Certifications/Licenses that your company requires for your primary areas of specialty
  15. [Add]

  16. Yes No
  17. Yes No
  18. Yes No
  19. Yes No
  20. Yes No
  21. How many employees does your company employ?
  22. Yes No
  23. Yes No
  24. Yes No
  25. 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