CONTRACTOR PREQUAL STATEMENT

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CONTRACTOR/SUPPLIER REGISTRATION STATEMENT

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Thank you for your interest in Wayne County Consolidated Jail construction project. In order to develop a profile of your Company, please complete this form and submit it by clicking the submit button at the bottom of the page and your company will be registered with Dan Teak, LLC for Wayne County Consolidated Jail construction project.

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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

Is your company

Please list the trades or other services that your Company is interested in bidding.

Is your company a certified
MBE (minority bus enterprise)
WBE (woman-owned bus enterprise)
VOSB or SDVSOB (Veteran owned small business)
WCE (Wayne County enterprise)

You will be required to submit copies of all current certificates when requested

Does your company have policies that provide for fair employment practices in compliance with employment laws?
How many persons does your company presently employ:
Total employees
Wayne County Residents
% minority employees
% female employees

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?

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?

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?

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.

Name of Company
Name of Officer Submitting Information
Title
Dated

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.

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