Vendor Prequalification Form

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Company Information
Company name
Federal ID #
Nameyour full name
Phone
Fax
Mailing Address
Mailing Address
City
State / Province
Zip / Postal Code
Street Address
Mailing Address
City
State / Province
Zip / Postal Code
Person of Contact
Name
Title
Work Phone
Cell Phone
Fax Number
Company Background
What work does your company perform, or what materials can your company supply?
0 /
Preferred Project Type:
Years in Operation
What is the typical size of a subcontract or purchase order for your company:
Last Year
2 years ago
Name
Title
Name
Title
Company Areas of Operation:
Can your company:
Is your company affiliated with any other company(s)?
Name
Address
Name
Address
Company Insurance Limits
General Liability
Auto Liability
Excess Liability
Does your company carry workers' compensation insurance?

All information requested in this section is required from contractors, subcontractors and other organizations whose services include providing labor beyond a customer's site

Provide the following rates for your company for the past three years:
Does your company qualify as a M/WBE firm?

We certify that all the information in this questionnaire and the attachments is true and correct. We hereby authorize Rivera • Rodríguez & Associates, llc. and its representatives to investigate directly with the references given herein, any information pertaining to the undersigned and/or the individuals involved therein. We authorize our financial institutions, prior and existing sureties,customers, creditors and suppliers to release credit history and other underwriting qualification information.

If this form is not filled out in its entirety, you may not be considered as a subcontractor or supplier.

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Date
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