Subcontractor Qualification Form Please provide the following information to be considered for inclusion on MSF Contracting Group's Subcontractor List. This form must be typed, hand writtem, or electronically submitted. Date Company NameCompany Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweCountry Contact Person for Estimates: How many years has your company been in business?What is your average yearly revenue of the last 3 years?What is your average project size?What is the dollar value of the largest project successfully completed by your company?What percentage of work is performed using your own forces?Can you provide a bond?YesNoIf yes, up to what dollar amount?Has your company ever failed to complete any work awarded during the past five (5) years?YesNoIf yes, please explain.Are there any pending or outstanding claims, arbitrations, or lawsuits against your firm?YesNoIf yes, please explainWhat work categories do you perform?Is your company Union?YesNoIf yes, please list the unions with which you are affiliatedWhat is the average size of your field work force?Does your firm qualify with any of the following?Small BusinessSmall Advantaged BusinessMBEWBEHub ZoneVeteran Owned Small BusinessPlease provide a representative list of General Contractor's who you have worked for. Are you willing to travel for projects outside of the DFW market?YesNoAre you willing to comply with the Equal Opportunity Employment (EEO) rules?YesNo SAFETY & HEALTH PERFORMANCEWorkers Compensation Experience Modifications Rate (EMR) DataHave you received any regulatory (EPA, OSHA, etc) citations in the last three (3) years?YesNoIf yes, please attach copies. SAFETY & HEALTH MANAGEMENTHighest ranking safety/health professional in the company: SAFETY & HEALTH PROGRAMS & PROCEDURESUntitledYesNo1. Do you have a written safety and health program?2. Do you have a written hazard communication program?YesNo3. Do your employees read, write and understand English such that they can perform their job tasks safely without an interpreter?YesNo4. Do you have personnel trained to perform first aid & CPR?YesNo5. Do you have a safety & health orientation program for new hires and newly hired or promoted supervisors?YesNo6. Have your employees received the required safety and health training and retraining?YesNoDo you hold site safely safely and health meetings for :Yes - Field SuperisorsYes - EmployeesYes - New HiresYes - SubcontractorsAre the safety and health meetings documented?YesNoInspections and AuditsDo you conduct safety and health inspections?YesNoDo you conduct safety and health program audits?YesNoAre corrections of deficiencies documented?YesNoAdditional Comments:Name:Title/ Position:Date This iframe contains the logic required to handle AJAX powered Gravity Forms.