CONTRACTOR APPLICATION

Company's Name:Phone:

Street: City:

State: Zip Code:

Company Type:

                    General Contractor:    yes          no

                    Sole Proprietor:           yes          no    Home Phone:

                    Partnership:                 yes          no     Work Phone:

                    Corporation:                yes          no

Specialties (check all that apply):

Electric         Plumbing         Heating         Roofing         Masonry

Other (please specify)

List of Company Owners

Name/Title:

Street: City:

State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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: Phone:

Name/Title:

Street: City:

State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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: Phone:

Name/Title:

Street: City:

State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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: Phone:

Does your company have at least the following amounts of insurance coverage?

Name of Company:

Name of Agent: Phone:  yes     no

Provide Proof of Above Coverage with this Application

Insurance Check

Public Liability: yes     no         Valid Through 

Property Damage:  yes     no         Valid Through 

Workmens Compensation:  yes     no         Valid Through 

General Information

Company's years in existence:

When were you established as an independent contractor?

How many tradesmen do you employ other than sub-contractors?

Can you handle more than one $10,000-$15,000 Housing Rehabilitation job at a time?     yes*     no   *If yes, how many?

Have you ever defaulted on a contract? yes*     no

*If yes, please explain:

Have you ever had a judgment file against you for failure to pay materialmen or subcontractors? yes*     no

* If yes, please explain:

To your knowledge, are you included on any Federal or State list of ineligible contractors? yes*     no

* If yes, please explain:

What is the largest job you have ever done?

Dollar amount: $

What is your yearly gross volume of contracted work (check only one, please)?

$0 to $25,000     $25,000 to $50,000     $50,000 to $100,000    Over $100,000

Over $250,000

Does your company have an equal opportunity policy which complies with federal regulations?  yes     no

Company Ownership:

(The following information is OPTIONAL and is only for statistical purposes)

(check one)             White:        Black:     Other:           

Male:         Female:

Recent jobs completed (Local)

1.) Name of Owner:

Street: City:

State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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: Phone:

Dollar amount and type of work:

2.) Name of Owner:

Street: City:

State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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: Phone:

Dollar amount and type of work:

3.) Name of Owner:

Street: City:

State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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: Phone:

Dollar amount and type of work:

I hereby give my permission to contact any or all of the above named parties and to verify the information included in this application.     check here if you agree

To be completed by agency staff:

Verification by: ____________________________________________________________

Suppliers contacted:

Company: __________________________________ Person: ________________________

Date: ____________________

Credit Comments: ___________________________________________________________

____________________________________________________________________________

Banking Information:

References:

Company: __________________________________ Person: ________________________

Date: ____________________

Credit Comments: ___________________________________________________________

____________________________________________________________________________

Job References Contacted:

Name: ______________________________________________

Type Job: ________________________________________________

Cost: _____________________________ Date: __________________________

Credit Comments: __________________________________________________________

___________________________________________________________________________

Name: ______________________________________________

Type Job: ________________________________________________

Cost: _____________________________ Date: __________________________

Reference Comments: __________________________________________________________

___________________________________________________________________________

Name: ______________________________________________

Type Job: ________________________________________________

Cost: _____________________________ Date: __________________________

Reference Comments: __________________________________________________________

___________________________________________________________________________

I CERTIFY THAT THE ABOVE IS TRUE AND COMPLETE AND I AUTHORIZE THE HOUSING REHABILITATION PROGRAM TO VERIFY ALL INFORMATION SUPPLIED ON THE APPLICATION AND OBTAIN A CREDIT REPORT.

                        Check here if you agree

Note: The Contractor is not required to resubmit this form if he was previously been approved, provided his/her statement is still true and has not changed.