Name of Company(required) Mailing Address(required) City & State(required) Zip Code(required) Phone Number(required) Fax Number(required) Contact Name(required) E-Mail (required) Description of subcontract work performed or products sold: As the listed address, company operates as:(required) Individual Proprietor Partnership Corporation Co-Venture Division Subsidiary Affiliate If Corporation, qualified to do business in If Affiliate, Affiliate of: Affiliate HQ located Branch Office of Company HQ located If a Supplier, what is Company's relationship with manufacturers?(required) Agent Manufacturer's Rep Independent Contractor Other How many years has your Company been in business as a subcontractor/supplier under the present business name? Union Affiliation of Company(required) Closed Shop (Union) Open Shop (Non-Union) Your organization's current EMR Name of Insurance Company Insurance Company Address Insurance Company Phone Are there now any liens, suits or judgments pending or outstanding, and unsatisfied as a result of the business operations of the Company, its officers or its predecessors?(required) Yes No List 3 Contractor References(required) The Pre-qualification Statement is submitted by the applicant with the full knowledge that the contents contained herein are to be considered as a true and accurate representation of the capabilities and financial capacity of the Company to perform work on the above subject project. Should information submitted be incomplete, Lanier Building, Inc. may not be able to consider the Company for the subject project qualified bidder's listing. (required) Firm(required) Signed(required) Date(required) Title
