J. Crowder Corporation

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Subcontractor Application

Names and Titles of Principal Contacts:
Principal Contact:
Title:
Phone: ()-
Fax: ()-
Email:

Estimating Contact:
Title:
Phone: ()-
Fax: ()-
Email:

Company Contact Information
Is this Main Office Regional Office Other
Shipping Address:
Street:
City:
State: Zip:

Mailing Address:
Street:
City:
State: Zip:

Phone: ( ) -
Fax: ( ) -
Web Address:

CSI DIVISIONS
Please select the CSI Category you fall under and provide a description of your services.

Description:

INFORMATION ON STATE CONTRACTORS LICENSE
Legal Name of Firm:

State: License No:
Class: Expiration Date: / /

Federal Tax ID Number:
Dunn & Bradstreet Number:
Company Type:
Date Formed: / /      State of Formation:
State Unemployment Insurance Number:
Do you have a parent company? Yes     No
If yes, please identify:
Do you perform services under any other name? Yes     No
If yes, please identify:
Is your company currently working on any projects for J. Crowder Corporation? Yes     No
If yes, please provide names:
Has your company worked for J. Crowder Corporation in the past? Yes     No

SAFETY
Experience Modification Rate for (YR) (rate)

CURRENT BONDING AND BANKING INFORMATION
Surety Company: Broker:
Contact Person: Phone: ( ) -

Name of your Bank:
Address:    City:
State:      Zip:
Contact Person:    Phone: ( ) -
Line of Credit: $    Unused Portion: $    Expiration Date: /

COMPANY MINORITY STATUS CERTIFICATION
County, City, State and Transportation Departments (check all that apply):
DBE (Disadvantaged Business Enterprise)
DVBE (Disabled Veterans Business Enterprise)
MBE (Minority Business Enterprise)
SBE (Small Business Enterprise)
WBE (Women Business Enterprise)

Federal Contracts (DoD)/ Small Business Administration:
(Small Disadvantaged Businesses and Hub Zone Businesses must be certified by the SBA. www.ccr.gov)
Check all that apply:
HBCU/MI (Historically Black Colleges Universities/ Minority Institutions)
HUB Zone-S (Historically Underutilized Business Zone)
LB (Large Business)
SB (Small Business)
SBA 8(a) (Small Business Administration)
SDB (Small Disadvantaged Business)
SD-VOSB (Service Disabled Veteran Owned Small Business)
VOSB (Veteran Owned Small Business)
WOSB (Women Owned Small Business)

Minority Ownership
Check all that apply:
Native American
ANC-LB (Alaskan Native Corporation and Indian Tribes-Large Business)
ANC (Alaskan Native Corporation and Indian Tribes)