SUBCONTRACTOR PRE-QUALIFICATION FORM Thank you for your interest in BENHAM CONSTRUCTORS, LLC. In order to develop a more complete knowledge of your Company and better match future Benham opportunities to your Company s capabilities please complete this form and return to: BENHAM CONSTRUCTORS, LLC 9400 N. Broadway, Suite 300 Oklahoma City, OK 73114-7401 Attention: Doug Shepherd - Procurement Phone: 405-607-6924 Fax: 405-478-3020 Date of Response: SUBCONTRACTOR/VENDOR PREQUALIFICATION STATEMENT Company Name: Address: City, State, Zip: FID Number: Web Site: Contact Name: Contact Phone No.: E-Mail Address: Fax No: ORGANIZATION Years Organization in business as a Contractor: Years operated under its present name: Date of Organization/Incorporation: Operated under any other names? Name of Parent Company Address: If operated any other names please explain: How are your organized? Corporation Partnership Sole Proprietorship Other (Explain) _ List Officers/Partners/Owners: If Corporation, state incorporated in: Is your Company MBE WBE DBE MBE/EBE/DBE certified by:
(Please attach a copy of all certifications) LICENSES List licenses and registrations held by your organization: Sales Tax Registration _ Federal ID Number: TRADES Please fill in the trade(s) that your Company is interested in bidding: Please indicate trade(s) you self perform: EXPERIENCE Note: If the answer to any of the questions below is yes, please provide and attach details. 1. Do you employ union trade labor? Yes No 2. Has your organization ever failed to complete any work awarded to it? Yes No 3. Are there any judgments, claims, arbitration proceedings or suits pending or outstanding against your organization or its Officers? Yes No 4. Within the last five years, has any officer or principal of your organization ever been an officer or principal of another organization when it failed to complete a construction contract? Yes No 5. Have any of the Owners, officers or major stockholders of your Company been indicted or convicted of any felony or other criminal conduct? Yes No 6. Has your Company ever had a claim made against it for improper, delayed, defective or non-compliant work or failure to meet warranty obligations? Yes No 7. Has your Company or any of its owners, officers or major stockholders been investigated for or charged with alleged labor violations including alleged violations of the Immigration Control and Reform Act, state or local laws regarding employment of immigrants, prevailing wage laws, wage and hour laws or other federal, state or local laws? Yes No REV 01/05.11.09drs 2
8. On a separate sheet, please list major construction projects your organization has contracted during the past 5 years, providing the name of the project, owner, architect, contract amount, date or completion (or percent complete and schedules completion date for work in progress) and percentage of the cost of the work performed with your own forces. Total value of work in progress: Dollars Total Value of work under contract: Dollars Average annual amount of construction work performed during the past five years: Dollars per Year Geographical Areas in which you will work: Indicate the size of project you are most competitive in performing (with an x) and show other size projects you are comfortable in performing (with a ): Under $50,000 $500,000 750,000 $2,000,000 - $3,000,000 $100,000 250,000 $750,000 - $1,000,000 $3,000,000 5,000,000 $250,000 50,000 $1,000,000 - $2,000,000 Over $5,000,000 What trades do you normally subcontract? What is the largest contract your company has completed to date: Amount: Year: Project Name: Scope of Work: Estimated Annual Volume for current year: Average Volume for 2010: 2009 2008 2007 REFERENCES 1. Trade Company Name: Contact Person: Company Name: Contact Person: REV 01/05.11.09drs 3
Company Name: Contact Person: 2. Bank Name of Bank: Contact Person: Do you provide data to Dun & Bradstreet and if so please provide your DUNS #. DUNS Yes No If you do not provide data to Dun & Bradstreet, please attach a financial statement, preferable audited, including your organization s latest balance sheet and income statement. Is the attached financial statement for the identical organization named on page one? If not, please explain the relationship and financial responsibility of the organization whose financial statement is provided (i.e. parent-subsidiary). Will the organization whose financial statement is attached act as a guarantor of the contract for construction? Yes No 3. Surety Name of Surety: Name of Agent: Is your company bondable? Yes No Bonding capacity per job Aggregate: Date of last Bond: Amount: Bond Rate: % 4. Major Suppliers/2nd Tier Subcontractors Company Name: Contact Person: Company Name: Contact Person: Company Name: Contact Person: REV 01/05.11.09drs 4
SAFETY Safety is an integral part of all BENHAM Constructors business and constitutes a significant factor in the final subcontractor/vendor selection. Should you or your lower tier Subcontractors have any questions regarding the requirements for completing the Contractor Safety Questionnaire please CONTACT Carolyn Jones at (405) 242-6299 for further assistance. Complete this attached form titled Contractor Safety Questionnaire and submit with Subcontractor Prequalification form. In addition, include the requested OSHA forms and Letter of Validation for your company EMR rates as referenced in the Contractor Safety Questionnaire. Subcontractors are also responsible for ensuring all lower tier Subcontractors submit the Contractors Safety Questionnaire, along with all supporting documentation, to BENHAM. BUSINESS SIZE AND CLASSIFICATION In accordance with government regulations and corporate policy requirements, we are required to get representation of the business size and classification to our suppliers and subcontractors. Is your organization certified by the Small Business Administration (SBA) or any other federal, state, or local government agency in any of the following categories? Please refer to the definitions below and mark all categories appropriately. HUBZone Business Small Disadvantaged Business Small Business Woman Owned Small Business Veteran Owned Small Business Historically Black College/University/Minority Institution (HBCU) Service Disabled Veteran Owned Small Business Disadvantaged Large Business Enterprise Other Category REV 01/05.11.09drs 5
SIZE INFORMATION Business Size Coding Definitions Small Business - The term "small business" shall mean a business as defined pursuant to Section 3 of the Small Business Act and relevant regulations issued pursuant thereto. Generally, this means a small business organized for profit that is independently owned and operated, is not dominant in the field of operations in which it is bidding, and meets the size standards as prescribed in government regulations. Consult your regional or district SBA office if further clarification is needed. Large Business - A business concern that exceeds the small business size code standards established by the SBA as set forth in the Code of Federal Regulations, Title 13, Part 121. Foreign Business - A business concern organized under the law of a country other than the US, its territories or possessions. A foreign business does not have a place of business located in the United States and does not make a significant contribution to the U.S. economy through payment of taxes and/or use of American products, material and/or labor, etc. Other foreign-owned business may be classified as a Small Business or a Large Business. Non-profit Organization - Any organization not conducted or maintained for the purpose of making profit (excluding HBCU/MI's). Included in this category are sheltered workshops, universities, colleges, and local, state and federal governments. Historically Black College/University or Minority Institution (HBCU/MI) - Historically Black Colleges and Universities (HBCU's) are institutions that were established before 1964 and have a principal mission that was, and is, the education of Black Americans and that meet the requirements set forth in the Code of Federal Regulations (CFR), Title 34, Part 608.2. Minority Institutions (MI's) are institutions that substantially increase the higher education opportunities for minority and/or low income students who are educationally disadvantaged or underrepresented in post-secondary education and meet the requirements set forth in Title 34 of the CFR, Part 607.2. Non-Profit Organization - National Institute for the Blind and National Institution for the Severely Handicapped (NIB/NISH) - National Industries for the Blind (NIB) and National Industries for the Severely Handicapped (NISH) are national not-for-profit agencies that create employment opportunities for people who are blind or severely disabled (http://www.nib.org and http://www.nish.org). OWNERSHIP INFORMATION Minority Owned - A business concern that is at least 51% owned by one or more minorities; or, in the case of any publicly owned business, at least 51% of the stock is owned by one or more minorities; and whose management and daily business operations are controlled by one or more minorities. Woman Owned - A business concern that is at least 51% owned by one or more women; or, in the case of any publicly owned business, at least 51% of the stock is owned by one or more women; and whose management and daily business operations are controlled by one or more women. SBA-Certified Small Disadvantaged Business - A business concern certified by the SBA as a Small Disadvantaged Business (SDB). SDB's must include a copy of their certification letter from the SBA or a copy of their CCR (formerly PRO- Net) profile showing SDB certification with this form. SBA-8(a) Small Disadvantaged Business - A business certified by the SBA as a socially and economically small disadvantaged business for consideration of government set-a-side contracting opportunities and business development. SDB-8(a)'s must include a copy of their certification letter from the SBA or a copy of their CCR (formerly PRO-Net) profile showing SDB certification with this form. SBA-certified HUBZone Small Business - A business concern certified by the SBA as a HUBZone Small Business. HUBZone Small Businesses must include a copy of their certification letter from the SBA or a copy of their CCR (formerly PRO-Net) profile showing HUBZone Small Business certification with this form. Veteran (American) Owned - A business concern that is at least 51% owned by one or more veterans, or in the case of any publicly owned business, at least 51% of the stock is owned by one or more veterans, and whose management and daily business operations are controlled by one or more veterans. Veteran means a person who served in the active military, naval, or air service, and who was discharged or released there from under conditions other than dishonorable as defined in 38 U.S.C. 101 (2.) Service - Disabled Veteran (American Owned) - A business concern that is at least 51% owned by one or more servicedisabled veterans, or in the case of any publicly owned business, at least 51% of the stock is owned by one or more service-disabled veterans, and whose management and daily business operations are controlled by one or more servicedisabled veterans or, in the case of a service-disabled veteran with permanent and severe disability, the spouse or permanent caregiver of a service-disabled veteran with permanent and severe disability. Service-disabled veteran means a veteran, as defined in 38 U.S.C. 101(2), with a disability that is service-connected, as defined in 38 U.S.C. 101(16). National Minority Supplier Development Council Certified (NMSDC) - A business that is certified by the National Minority Supplier Development Council. A copy of the NMSDC Certification must be provided. NMSDC provides increased procurement and business opportunities for minority businesses of all sizes. The NMSDC network includes a national office in New York and 39 Regional Councils across the country. Regional Councils certify and match with member corporations which want to purchase goods and services. National Association of Women Business Owners (NAWBO) - A due's based organization that represents the interests of women entrepreneurs in all types of businesses. NAWBO works to: strengthen the wealth creating capacity of members and promote economic development; create innovative and effective changes in the business culture; build strategic REV 01/05.11.09drs 6
alliances, coalitions and affiliations, and transform public policy and influence opinion makers (http://www.nawbo.org/home.php). Women's Business Enterprise National Council (WBENC) - An organization formed to advocate and provide growth and development opportunities for women business owners. WBENC is a national third party certifier of a business owned and operated by women (http://www.wbenc.org). Provide a copy of the Women's Business Enterprise National Council and indicate certification date. OWNER ETHNICITY INFORMATION Asian Pacific American - Persons with origins from Burma, Thailand, Malaysia, Indonesia, Singapore, Brunei, Japan, China (including Hong Kong), Taiwan, Laos, Cambodia (Kampuchea), Vietnam, Korea, The Philippines, U.S. Trust Territory of the Pacific Islands (Republic of Palau), Republic of the Marshall Islands, Federated States of Micronesia, the Common Wealth of the Northern Mariana Islands, Guam, Samoa, Macao, Fiji, Tonga, Kiribati, African American - Persons having origins in any of the black racial groups of Africa. Hispanic American - Persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Native American - American Indians, Eskimos, Aleuts or Native Hawaiians. Subcontinental Asian American - Persons with origins from India, Pakistan, Bangladesh, Sri Lanka, Bhutan, the Maldives Islands or Nepal. North American Industry Classification Code Systems (NAICS) North American Industry Classification Code Systems (NAICS) - Insert the primary NAICS code if known and all secondary NAICS codes that identify the business establishments according to various business classifications. NAICS replaced the Standard Industrial Classification (SIC) NOTICE: In accordance with 15 U.S.C. 645(d), any person who misrepresents a firm's proper size classification shall (1) be punished by imposition of a fine, imprisonment or both; (2) be subject to administrative remedies; and (3) be ineligible for participation in programs conducted under the authority of the Small Business Act. Additional Information Please list any additional information you feel will help us determine your company s qualifications and expertise: I hereby certify that the above information is accurate, correct and true. Completed By: (Name) (Title) (Signature) (Date) NOTE: BENHAM CONSTRUCTORS, LLC REQUIRES AN ACORD INSURANCE CERTIFICATE ON FILE INDICATING AUTO, GENERAL LIABILITY AND WORKER S COMPENSATION This document is the property of BENHAM. It shall not be reproduced, copied or used other than for the intended purposes of the referenced Project without written permission of BENHAM. NO SUBCONTRACTOR WILL BE PRE-QUALIFIELD WITHOUT INSURANCE OF FILE AND AN APPROVED SUBCONTRACTOR SAFETY QUESTIONNAIRE, INCLUDING ALL SUPPORTING DOCUMENTATION REV 01/05.11.09drs 7