16 Tech Innovation District Projectmorgangillard2021-04-30T20:59:54+00:00 Name Subcontractor and Supplier Interest Form Vendor Information Legal Name Under Which You Do Business * DBA * Current Street Address * City * State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 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. * License No. License No. State: * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State: - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State: - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Type: * Type: 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 *
