CONTRACTOR’S QUALIFICATION FORM

Please answer all questions and have your statement notarized. If necessary, you may answer
questions on separate sheets of paper and attached them to this statement. Any additional
information your firm deems useful in the evaluation of your capabilities may also be included.
Please return this form via fax or mail prior to the Qualification Form due date. Should you have
any questions, please call.

Date of Response: ___________________

Firm Name: _____________________________________________________________

Street Address: ___________________________________________________________

City: _________________________________ State: _________________ Zip: _______

Mailing Address: _________________________________________________________

City: _________________________________ State: __________________ Zip: ______

Phone: __________________________________ Fax: ___________________________

Website: ________________________________________________________________

Contact: ________________________ Phone: ________________ Mobile: __________

Email Address: ___________________________________________________________

Is your company: (Please circle one listed below)

MBE WBE DBE MBE/WBE/DBE Certified by: _______________________

Is the address of the business listed above a:(Please circle one listed below)

Main Office Regional Office Branch Office

Name of Parent Company: __________________________________________________

Address of Parent Company: ________________________________________________

Phone: _________________________________ Fax: ____________________________

Contact Person: __________________________________________________________

Please list the trade(s)/bid package(s) your Company is interested in bidding:

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Year Company Started: ________

Type of Company: (Please circle one)

Corporation Partnership Proprietorship Sub S. Corp.

State of Incorporation: _____________ Date of Incorporation: ___________________

Contractors License Number: ___________________ State: ______ Expiration: ___________

(Attach list if needed)

State Sales Tax Registration Number: ________________________(Attach list if needed)

State Unemployment Number: ______________________________(Attach list if needed)

Federal ID Number: ____________________________

Please list all corporate officers, partners, members, and shareholders of more than 5% of the
stock of your company:

Name Position/Title Percent Owned

_______________________ _______________________ _____________

_______________________ _______________________ _____________

_______________________ _______________________ _____________

_______________________ _______________________ _____________

_______________________ _______________________ _____________

______________________ _______________________ _____________

Under what other name has your company operated? ___________________________________

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How many people does your company currently employ?

Home Office _______ Field Supervisory _______ Craftsman _______

How many people did your company employ on average for the past 3 years?

Home Office _______ Field Supervisory _______ Craftsman _______

Has your company or any of its principals ever 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 even been indicted or
convicted of any felony or other criminal conduct?

____Yes ____No

If yes, please explain: ____________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Has your company ever been banned or otherwise precluded from pursuing public work or have
ever been found to be non-responsive by a public agency?

____Yes ____No

If yes, please explain: ____________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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Has your company ever had a claim made against it for improper, delayed, 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 your company have any outstanding judgments or claims against it? ____Yes ____No

If yes, please explain: ____________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Please list any litigation brought against your company in the past five (5) years asserting that
you failed to make payments to anyone.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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List the geographical areas in which you work: _______________________________________

______________________________________________________________________________

List Unions that you have agreements with:

Local Number Union Name Agreement Expiration

_____________ _______________________________________ __________________

_____________ _______________________________________ __________________

_____________ _______________________________________ __________________

_____________ _______________________________________ __________________

List the areas of work that you normally perform with your own forces: ____________________

______________________________________________________________________________

What percentage of the Company’s work is normally subcontracted? ___________%

What is the largest contract your company has completed?

Amount $_________________Year ______ Project Name and Scope: _____________________

______________________________________________________________________________

What is the largest contract you are currently working on this year?

Amount $____________ Project Name and Scope: ____________________________________

______________________________________________________________________________

What is your expected annual volume this year? $_________________ # Of Projects _________

What is your average volume of work performed over the past 5 years?

Year: _______ Volume: _______________

Year: _______ Volume: _______________

Year: _______ Volume: _______________

Year: _______ Volume: _______________

Year: _______ Volume: _______________

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List the projects you believe your firm is currently a low bidder, will be awarded, or are strongly
being considered for and the contract amount:

Project Contract Amount Project Duration

________________________________________ _________________ _____________

________________________________________ _________________ _____________

________________________________________ _________________ _____________

________________________________________ _________________ _____________

Attach a list of projects in progress and currently under contract giving the name of the project,
project address, owner, architect, general contractor/construction manager, contract amount,
scope of work, and scheduled completion. (Include contact people and phone numbers)

Attach a list of completed major projects completed in the last 5 years giving name of the
project, project address, owner, architect, general contractor/construction manager, contract
amount, and scope of work. (Include contact people and phone numbers)

Attach a copy of your latest financial statement.

If the attached financial statement is not for the identical Company named above, explain
relationship and financial responsibility of the Company whose financial statement is provided:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Name of your Bank: _____________________________________________________________

Address: ______________________________________________________________________

Phone: _______________________ Contact Person: _______________________

Amount of line of credit: ___________ Amount Available: _____________________

Expiration Date: _________________ UCC Filing? ____Yes ____No

How is credit secured? ___________________________________________________________

What is your Company’s Dunn & Bradstreet Number? _________________________________

D&B Rating: __________ Pay Record: ____________ Date of Rating: _____________

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Bonding Company: _____________________________________________________________

Address: ______________________________________________________________________

Contact Person: ___________________________ Phone: _______________________________

Bonding Company’s Rating: ______________

Bonding Capacity: Per Job $_____________________ Aggregate $_____________________

Date of Last Bond: ________________ Bond Amount $_____________________

Bond Rate: ___________________ Remaining Bonding Capacity $_____________________

Please list the persons or entities that provide indemnification to your Surety: _______________

______________________________________________________________________________

______________________________________________________________________________

List three of your major suppliers:

A. Company: _______________________________________________________________

Address: ________________________________________________________________

Phone: _____________________________ Fax: ________________________________

Contact: _________________________________________________________________

B. Company: _______________________________________________________________

Address: ________________________________________________________________

Phone: _____________________________ Fax: ________________________________

Contact: _________________________________________________________________

C. Company: _______________________________________________________________

Address: ________________________________________________________________

Phone: _____________________________ Fax: ________________________________

Contact: _________________________________________________________________

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List three Contractors/Owners you do business with:

A: Company: _______________________________________________________________

Address: ________________________________________________________________

Phone: _____________________________ Fax: ________________________________

Contact: _________________________________________________________________

B. Company: _______________________________________________________________

Address: ________________________________________________________________

Phone: _____________________________ Fax: ________________________________

Contact: _________________________________________________________________

C. Company: _______________________________________________________________

Address: ________________________________________________________________

Phone: _____________________________ Fax: ________________________________

Contact: _________________________________________________________________

Trade Association Memberships: ___________________________________________________

______________________________________________________________________________

List national accredited training programs in which you participate (craft or management
training): ______________________________________________________________________

______________________________________________________________________________

List any subsidiaries and affiliates of your company:

Company Name Ownership Type of Company

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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List key office personnel and field supervisors:

Name Position Years Experience

____________________________ ______________________________ _______________

____________________________ ______________________________ _______________

____________________________ ______________________________ _______________

____________________________ ______________________________ _______________

____________________________ ______________________________ _______________

____________________________ ______________________________ _______________

Please list your company’s Workers’ Compensation Interstate Experience Modification Rate for
the most recent three years. (Attach a copy of your insurance carrier or state fund (on their
letterhead) verifying the EMR data.)

Interstate (Yr./Rate)

________/________ ________/________ ________/________

Note: TRADE CONTRACTORS must have a current EMR less than or equal to 1.0 to qualify
for Lamp Incorporated’s bid list. Should your EMR exceed 1.0, the Contractor must
demonstrate and document that it has or will initiate programs, policies and attitudes which will
result in a safety conscious performance in order to be included on Lamp Incorporated’s
Approved Contractor List. In this case it is the sole discretion of Lamp Incorporated to approve
or disapprove a TRADE CONTRACTOR.

Please attach a copy of your OSHA 300/200 logs for the past three years

How many OSHA violation(s) has your Company received in the last three years?

(Yr. = # violations) ______ = ______ ______ = ______ ______ = ______

Any willful OSHA violations? ____Yes ____No

Please give a brief description of the violation(s): (use additional paper if necessary)

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

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Any project site deaths in the past 3 years? ____Yes ____No

If yes, please give a brief description of the circumstances:________________________

________________________________________________________________________

________________________________________________________________________

Do you have a qualified person responsible for safety within your company?

____Yes ____No If yes, is this a full time position? ________

If this is not a full time position, how many hours per week is dedicated to safety? ________

Does your company have a written safety policy? __________

If yes, when was it first written and has it been updated recently? Please list dates:

Year Created: _________ Revisions: ____________________________________

Are weekly toolbox safety meetings conducted? _________

If no, why not? _________________________________________________________________

______________________________________________________________________________

Are records maintained of each weekly toolbox meeting? ____________

If no, why not? _________________________________________________________________

______________________________________________________________________________

General Remarks: _______________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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We have attempted to answer all questions in a full and complete 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 Lamp Incorporated will be relying on
the accuracy of the information and our responses in this questionnaire in deciding whether to
permit us to bid and in awarding work to our Company.

Dated at _____________________ this________ day of __________________, 20 _____

Name of Company: ____________________________

Completed by: _________________________________ (Must be an officer of the company)

Title: ________________________________________

Signature: ____________________________________

_________________________ being duly sworn deposes and says that the information provided
herein is true and sufficiently complete so as to not be misleading.

Subscribed and sworn before me this ________ day of __________________, 20 ______

Notary Public: ________________________________

My commission expires: ________________________

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