Contact Renaissance Builders, LLC

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All Fields Required

1. Subcontractor Indentity

Area(s) of Expertise:
Company Name:
Address:
City:
State:	State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey 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
Zip:
Phone Number:
Fax Number:
Tax ID or SS Number:
Email:
Type of Company:	Sole Proprietorship
	Corporation
	Partnership
Date Company Formed:
Total Number of Employees:
States in which the company is legally qualified to do business:
Names and titles of key people in company:
Has the company operated under any other name in the past five years?	Yes No
If Yes, give name(s):
Does the company have offices, plants, or warehouses at other locations?	Yes No
If yes, list address(es):

2. MBE/WBE/SBE Certification

Is the company a certified Minority Business Enterprise (MBE), Women Business Enterprise (WBE), Small Business Enterprise (SBE), or any other type of certified business enterprise?	Yes No
If yes, which type:
Certifying Agency:

3. Financial Information

Does the company have a line of credit from any lending institution	Yes No
If yes, give details:
Lenders Name
Address Lending Officer's Name
Phone Number:
Do you have bonding?	Yes No
If yes, give details:
Single project limit:
Aggregate Limit:
Bonding Company
Name:
Address:
City:
State:	State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey 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
Zip:
Bonding Agent
Name:
Address:
City:
State:	State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey 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
Zip:
Phone Number:

4. Safety Record

In the past five years, has your company or any of its key people been investigated for or found to have committed a serious OSHA violation?	Yes No
If yes, give details:
Please indicate your current Workman’s Compensation MOD rate:
Attach a copy of the current MOD sheet:
Do you have a written employee safety policy and program?	Yes No
Do you have a designated company safety officer?	Yes No
If yes, please provide their name and phone number:
Do you have a hazardous communications program, and are you able to provide MSDS’ for any hazardous products you may use?	Yes No
Do you conduct project safety inspections?	Yes No
If so, who conducts the inspection (name and title) and how often?
Please attach a copy of your most recent OSHA 300 log and a copy of your 3-year loss history for liability insurance:
OSHA 300 log:
3-year Loss History:
Are there any other open or aggregate liability claims that would impair your ability to insure any project?	Yes No
Explanation:

5. Other Information

Has your company or any of its people been a party to a bankruptcy or reorganization proceeding?	Yes No
If yes, give date:
During the past five years, have any liens been filed against you by any of your subcontractors or suppliers?	Yes No
If yes, give details for any liens over $5,000:
Have you ever failed to complete a contract, been defaulted, or had a contract terminated?	Yes No
If yes, give details:
IN the past five years, has your company or any of its key people been involved in any lawsuits arising from construction projects?	Yes No
If yes, give details:
Is there any other information you would like to give us?
I hereby certify that to the best of my knowledge all of the information on this form is correct.
Sign Your Name (Signed):
Title:

6. Completed Projects (Summarize representative projects completed in past 5 years)

Name of Project	Scope of Work	Contract Amount	Completion Date

7. Current Projects (Work in Progress)

8. Trade References (List three of your subcontractors or Suppliers)

9. Client References (List three clients)

Name	Address	Phone Number	Contact Name