Sub-Contractor Registration

Please complete the following sections:

Company Name:
Trade:
Division Number:
Address:
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Lousiana 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 Wisconson Wyoming
Zip:
Contact Person:
Title:
Email:
Phone:
Fax
Cell Phone
Website
If you have difficulty ascertaining your size status, please refer to SBA's website at www.sba.gov/size or contact your local SBA office.
	Certified by SBA as a Small Disadvantaged Business
	Certified by SBA as an 8(a) Business
	Woman Owned Small Business
	Veteran Owned Small Business
	Service Disabled Veteran Owned Small Business
	Minority Institution or Historically Black College/University
	Small Business
	Union
	Non-Union
	Other: Specify
No. of Employees:
Does your company have a Safety Policy and Program?
Contractor License No.:
Issuing State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Lousiana 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 Wisconson Wyoming
Type
Expires
Bonding Capacity Per Job:
Aggregate
Region / area(s) your company is interested in doing business:
List completed project examples including completion date, owner, reference contact, contract amount and work performed.
Completion Date Owner Reference Contact Phone Number Contract Amount Work Performed
Vendor references
Company Name Contact Name Phone Fax
Your Company's Contract Size	Capabilities: (click all that apply)
	Under $100,000
	$100,000-$200,000
	$200,000-$500,000
	$500,000-$1,000,000
	$1,000,000-$3,000,000
	$3,000,000-$6,000,000
	$6,000,000-$9,000,000
	$10,000,000-$15,000,000
	Over $15,000,000
	Other: $
Has your Company ever been terminated for default on any Contract?
	Yes
	No
Has your Company ever been disbarred from doing business with any governmental agency?
	Yes
	No
Comment
Certification and Privacy Notice:
Perera Construction & Design will review the information furnished, but is relying upon your Company to furnish Perera Construction & Design with truthful and accurate information. Accordingly, to the best of the Company's knowledge as of the date of this Prequalification Submission, the information contained herein is truthful, accurate and current. Your Company further understands that by submitting this form, Perera Construction & Design does not guarantee or promise any work to your Company, nor should this be construed to be an offer of any work. The purpose of this submission is prequalification only. Your Company also understands that the information provided is not intended to be confidential or private, and it shall be not treated as such.
BEFORE APPROVAL PLEASE FAX THE FOLLOWING TO Debbie 909-484 3439:
Copy of Contractor's License Sample of insurance: Auto, General Liability, Workers Compensation Copy of your MBE / WBE / DVE certificate (if applicable)
Type the code on the image (The code is case sensitive):	(Click here if you can't read the code)