HOME / SUBCONTRACTORS AND VENDORS SUBCONTRACTORS AND VENDORS Pellicano Construction requests that all subcontractors and vendors complete the qualification form: GENERAL INFORMATION Select One of the Following* SOLE PROPREITORSHIP PARTNERSHIP CORPORATION SUB-S CORP. NAME OF FIRM* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code YEAR FIRM BEGAN OPERATION TOLL FREE NUMBER CORPORATE OFFICERS- PARTNERS-PROPRIETORSHIP NAME AGE POSITION YEARS W/ FIRM IN THIS POSITION % OF OWNERSHIP Please enter a number from 0 to 100. NAME AGE POSITION YEARS W/ FIRM IN THIS POSITION % OF OWNERSHIP Please enter a number from 0 to 100. NAME AGE POSITION YEARS W/ FIRM IN THIS POSITION % OF OWNERSHIP Please enter a number from 0 to 100. Type of work your firm specializes in: List the geographic areas (States) where your firm is licensed to do business: ESTIMATING CONTACT: Name Email Phone PRESIDENT OR LOCAL MANAGER: Name Email Phone Does your organization have in-house design/engineering capabilities? Yes No If so, does your firm carry professional Liability (errors & omissions) Insurance? Yes No Would you be willing to provide current financial statements when requested? Yes No DIVERSITY Certified Minority Business Enterprise? Yes No CERTIFICATION DATE MM slash DD slash YYYY CERTIFICATION CITY CERTIFICATION STATE BONDING INFORMATION Name of Bonding Company (not agent) BONDING AGENT NAME ADDRESS PHONE BOND RATE LARGEST BONDED JOB BONDING CAPACITY: SINGLE:$ BONDING CAPACITY: AGGREGATE:$ ESTIMATED UNUSED BONDING CAPACITY LARGEST ANNUAL VOLUME AT ANY ONE TIME YEAR HISTORY/ JOB EXPERIENCE Average Annual Volume Largest Project Completed Current Backlog PROJECT REFERENCES List below three (3) largest jobs compiled in the past three (3) years; including person to contact, phone number, contract amount and work performed: JOB NAME OWNER TO CONTACT Phone AMOUNT OF CONTRACT WORK PERFORMED JOB NAME OWNER TO CONTACT Phone AMOUNT OF CONTRACT WORK PERFORMED JOB NAME OWNER TO CONTACT Phone AMOUNT OF CONTRACT WORK PERFORMED INSURANCE INFORMATION Experience Modification Rate (EMR): INSURANCE COMPANY AGENCY (G/L & WORKERS COMPENSATION) Name/Contact Address Street Address City State / Province / Region ZIP / Postal Code Phone Pellicano Construction is hereby authorized to investigate the references listed pertaining to performance and financial responsibility Signed on MM slash DD slash YYYY Name of Company Signed By Title VIEW OUR PROJECTS CONTACT US MENU: Home About Us Our Projects Services Resources Contact us FTP Site ALBANY: 415 Pine Avenue, Suite 200 Albany, GA 31701 Phone (229) 883-6000 Fax (229) 883-4220 ATHENS: 540 Baxter Street, Suite A Athens, GA 30605 Phone (770) 766-0076 Fax (770) 766-0116 ATLANTA: 990 Hammond Drive, NE Bldg. 1, Suite 825 Atlanta, GA 30328 Phone (770) 542-2400 Fax (770) 542-2405 MACON: 153 Gateway Drive, Suite B Macon, GA 31210 Phone (478) 254-2772 Fax (478) 254-3532 SOCIAL: © 2021 Pellicano Construction | ALL RIGHTS RESERVED