Business Name
Street
Address1
Street
Address2
City
State
Zip Code
Phone Number1
Phone Number2
FAX Number
Name of Contact Person
Contact's Phone Number
Ext
Cell
Contact's
Email
Your
Company website
Is
the address above
Main Office
Regional Office
Branch Office
Is
your company
Architect / Engineers
General Contractor
Specialty Contractor
Supplier (with limited installation services)
Non-construction Contractor
Please list the trades or other services that your Company is interested in
bidding.
Is
your company a certified
MBE
(minority bus enterprise)
No
Yes
WBE
(woman-owned bus enterprise)
No
Yes
VOSB or SDVSOB (Veteran owned small business)
No
Yes
WCE
(Wayne County enterprise)
No
Yes
You
will be required to submit copies of all current certificates when
requested
In
the last 3 years has your company or any of its principals petitioned
for bankruptcy, failed in business, defaulted or been terminated
on a contract awarded to you?
Yes
No
If
yes, please explain
Have
any of the owners, officers or major stockholders of your Company
ever been indicted or convicted of any felony or other criminal
conduct?
Yes
No
In
the last 3 years has your Company or any owners, officers or major
stockholders ever been suspended, disbarred or otherwise precluded
from pursuing public work or ever been found to be non- responsive
by a public agency?
Yes
No
In
the last 3 years has your Company had a claim made against it for
improper, delayed, defective or non-compliant work or failure to
meet warranty obligations?
Yes
No
If
yes, please explain
Is
your Company or any of its owners, officers or major shareholders
currently involved in any arbitration or litigation?
Yes
No
If
yes, please explain
Does
you Company have any outstanding judgments or claims against it?
Yes
No
If
yes, please explain
In
the past three (3) years has any litigation brought against your
Company asserting that you failed to make payments to anyone?
Yes
No
If
yes, please explain
Is
your Company a union contractor?
No
Yes
ALL CONTRACTORS AND SUPPLIERS (Including Non-Construction
suppliers)
Please
list your Company's Workers' Compensation Interstate/Intrastate
Experience Modification Rate for the most recent three years.
INSURANCE
QUESTIONNAIRE
Does
your Company have a Commercial General Liability Insurance
Policy currently in force?
No
Yes
Does
your Company have a Worker's Compensation and Employer's Liability
Insurance Policy currently in force?
No
Yes
Does
your Company have a Professional Liability Insurance Policy
currently in force?
No
Yes
I
am an authorized officer of the Company described as the "Business"
above. I hereby represent on behalf of our company that all answers
provided in this Contractor Registration Statement is true and
correct. We have attempted to answer all questions in a manner to
assure that our answers are not in any respect misleading, either by
expressing ourselves in a misleading or ambiguous manner or omitting
information. We recognize that Wayne County Detention Facility Project
Managers will be relying on the accuracy of the information and our responses
in this questionnaire in deciding whether to permit us to bid
on available work or be paid for goods and services supplied to the
Project.
Form
Filling Instructions: Please remember, once you click the button
Submit (below) the information will be submitted as final. If you
click on the "Return to Form" you will go back to a blank
form. All submissions are final, therefore it is recommended you
gather ALL your information together before filling the form.
