16 Tech Innovation District Project – Nubian Construction Group

Subcontractor and Supplier Interest Form

Vendor Information

Legal Name Under Which You Do Business

DBA

Current Street Address

City

State

ZIP Code

Contact Person's Name

Title

Email Address

Phone Number

Fax Number

Website

Number of Employees:

Full-Time:

Part-Time:

No. of Yrs. in Business

Annual Volume

Area(s) of Specialty/NAICS Code(s):

Business Geographical Area(s):

Are you certified by the City of Indianapolis?

Yes

No

Interested in becoming certified

Please check all certifications your company holds with the City:

MBE

WBE

VBE

DOBE

VOSB

Is your company certified by the State of Indiana?

Yes

No

Interested in becoming certified

Does your firm share office space, staff, or equipment with any other company?

Yes

No

If yes, explain:

Has your firm ever been denied certification, decertified, or graduated from any certification program?

Yes

No

If yes, explain:

Signatory to Union

Local #

Licenses:

License No.

State:

Type:

Bonding:

Project Limit

Bonding Company

Broker / Agent

Safety — Current EMR

Aggregate Limit

A.M. Best Rating

Phone No.

As a Subcontractor, I am Interested in providing quotes for the following scopes:

Professional Services Scopes:

Construction Services Scopes:

Please list 3 projects your firm has completed within the last 18 months—include project name, general contractor, contract value, and scope of work.

Project Name

General Contractor

Contract Value

Scope of Work

Project Name

General Contractor

Contract Value

Scope of Work

Project Name

General Contractor

Contract Value

Scope of Work

Please list 3 project references, including company name, contact person, and telephone number:

Company Name

Contact Person

Phone Number

Company Name

Contact Person

Phone Number

Company Name

Contact Person

Phone Number

Minimum Contact Size

Maximum Contact Size

Brief Statement of Capabilities

By entering my name below, I verify that the information provided on this form is accurate.

Signature of applicant:

Your typed name above serves as your digital signature.

Date