Company Information
Company Name
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Contact Name Contact Name First Last
Phone Phone - ### - ### ####
Fax Fax - ### - ### ####
Email
Organization
Drop Down
Is your firm registered with the State of North Carolina to do Business?

Is your firm registered with the State of North Carolina to do Business? Yes No
List all of the Owners, officers, and partners authorized to conduct business on behalf of firm
How long has the firm been in the contracting business?
Does your company qualify as a minority-owned, woman-owned, or small business? If yes, check all that
apply:

Does your company qualify as a minority-owned, woman-owned, or small business? If yes, check all that
apply: MBE WBE SBE Other Other
Please list all licenses that your firm currently holds for North Carolina.
Please take a few minutes to let us know what type(s) of work your firm is qualified to perform. Only check the work your own forces can accomplish. Do not check the work that you subcontract.
Hauling

Hauling 050 Hauling (Gravel, Sand, Debris, etc. – Not Asphalt) 055 Hauling (Asphalt)
Landscaping & Erosion Control

Landscaping & Erosion Control 1605 Temporary Silt Fence 1630 Silt Detention Device (Silt Basin) 1660 Seeding and Mulching 1670 Landscape Planting 16607 Mowing
Concrete and Masonry

Concrete and Masonry 825 Incidental Concrete Construction 830 Brick Masonry Construction 840 Minor Drainage Structures (Drop Inlets, Catch Basins, etc.) 846 Curb and Gutter/Shoulder Berm Gutter 848 Sidewalk, Driveways, and Wheelchair Ramps
Drainage

Drainage 310 Pipe Installation
Utility Installation

Utility Installation 1400 Roadway Lighting 1510 Water/Sewer Installation 2005 Directional Boring/ Directional Drilling 2010 Utility Installation/Removal: Gas 2020 Utility Installation/Removal: Power/Electricity 2030 Utility Installation/Removal: Telephone 2040 Utility Installation/Removal: Cable Television
Highway Preparation and Grading

Highway Preparation and Grading 200 Clearing and Grubbing 205 Sealing Non-Environmental Wells 210 Building Removal and Demolition 225 Roadway Grading and Excavation 501 Chemical Stabilization 520 Aggregate Base Course 560 Shoulder Construction 607 Milling Asphalt Pavements 801 Construction Surveying 1601 Stream Restoration and Construction 1651 Selective Tree Removal/Trimming
Paving

Paving 060 Asphalt/Concrete Saw Cutting 610 Asphalt Paving 654 Asphalt Pavement Repair 657 Crack and Joint Seal (Asphalt Pavement) 659 Microsurfacing and Slurry Seal 660 AST– Chip Seal 710 Concrete Pavement (Highways, not Sidewalks or Driveways) 711 Concrete Pavement Repair 712 Sawing and Sealing Joints 713 Diamond Grinding
Highway Finishing

Highway Finishing 665 Milled Rumble Strips 862 Guardrail Installation 865 Guiderail Installation 866 Fence Installation 900 Permanent Signing 1204 Symbols, Characters, Markers, Non-Truck Lines 1206 Pavement Markings - Paint 1207 Pavement Markings-Thermoplastic 1208 Pavement Markings – Poly-Urethane 1209 Pavement Markings – Cold Applied 1210 Pavement Markings - Epoxy 1251 Pavement Markers
Work Zone Safety

Work Zone Safety 1105 Work Zone Traffic Control Devices 1110 Work Zone Signs (Ground Mounted and Barricade Mounted)
Structures

Structures 080 Noise Walls 421 Concrete Structures (Box Culverts) 422 Concrete Structures (Bridges) 423 Grooving Bridge Floors 425 Reinforcing Steel (Placing and Tying) 440 Steel Structures (Steel Superstructure Bridges only) 442 Painting Steel Structures (Bridges) 460 Concrete Barrier Bridge Rail 1072 Welding 3010 Retaining Walls (Cantilever) 3015 Retaining Walls (MSE)
Signals and ITS

Signals and ITS 1407 Wood Pole Installation 1700 Traffic Signals and ITS 1730 Utility Installation/Removal: Fiber Optic Cable 1740 Metal Pole Installation
Buildings - Vertical Construction
Rest Area, Welcome Center, etc.

Buildings - Vertical Construction
Rest Area, Welcome Center, etc. First option 4000 Building, Framing 4010 Plumbing 4020 Mechanical (HVAC) 4030 Electrical 4040 Masonry (Buildings, not drainage structures) 4080 Doors and Windows 4090 Carpet 4100 Tile 4110 Toilet Accessories 4120 Toilet Partitions 4130 Signs (inside the building) 4140 Painting 4150 Irrigation/Lawn Sprinkler Systems 4180 Well Drilling 4190 Building Movers
Weigh Station Construction

Weigh Station Construction 4510 Weigh-in-Motion 4520 Transponder Readers
Geotechnical

Geotechnical 075 Rock Slope Stabilization 220 Blasting 411 Drilled Piers for Bridges 3020 Retaining Walls (Anchored) 3030 Drilled Piers for Metal Poles 3040 Contaminated Materials Removal 3045 Drilling for Geoenvironmental Investigations 3050 Drilling for Geotechnical Investigations 3060 Pile Driving Analyzer (PDA) 3065 Crosshole Sonic Logging (CSL) 3070 Non-Destructive Foundation Testing 3080 Foundation Testing 3100 Micropiles 3110 Continuous Flight Auger (CFA) Piles 3120 Vibration and Noise Monitoring 3125 Structure Movement Monitoring 3130 Ground Improvement Methods
Railroad

Railroad 5010 Track Construction 5020 Grade Crossing Signal Systems 5030 Train Control Signal and Communication Systems 5040 Railroad Electrical Traction Systems 5050 Track Maintenance/Rehabilitation 5060 Timber Structures (Bridge) 5070 Railroad Signage 5080 At -Grade Crossing Surfaces 5090 Right-Of-Way Prime Contractor
Disaster Recovery

Disaster Recovery 6000 Disaster Debris Removal
Aviation

Aviation 8010 Airfield Concrete Paving 8020 Airfield Asphalt Paving 8060 Airfield Signage 8070 Airfield Electronics and Navigation Aids 8080 Airfield Hangars/Metal Buildings 8100 Airfield Markings 8130 Airfield Fuel Farms
Marine

Marine First option 9100 Vessel Construction (Ferry) 9101 Vessel Repair (Ferry) 9200 Dock/Pier Construction
Other (Please list)
Work Experience

List the three projects your firm has performed and completed during the last 5 years.
Project 1
Project Name/Location
Brief Description
Owner/Representative
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
Contract Amount
Date of Completion
Project 2
Project Name/Location
Brief Description
Owner/Representative
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
Contract Amount
Date of Completion
Project 3
Project name/Location
Brief Description
Owner/Representative
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
Contract Amount
Date of Completion
Bonding

If Bondable, please provide Bonding Company Name, Address, Phone, Email and Contact Name:
Company Name
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
Contact Name
Insurance

Firms must indicate that they can provide evidence of insurance coverage, should they be approved as a subcontractor by attaching a copy of their insurance certificate.
- Workers Compensation Insurance as required by law and Employer’s Liability Insurance Coverage with minimum limits of $500,000 per occurrence.
- Comprehensive General Liability with minimum limits of $1,000,000 per occurrence/$2,000,000
  aggregate for personal injury and $1,000,000 per occurrence/$2,000,000 aggregate for property damage.
- Commercial Motor Vehicle with minimum limits of $1,000,000 per person for bodily injury and $1,000,000 per occurrence for property damage and $2,000,000 general aggregate.
LITIGATIONS/CLAIMS
Multiple Choice

Multiple Choice Yes No
If yes, please explain:
Are there currently any judgments, claims, arbitration or mediation proceedings or suits pending or outstanding against your company, officers, owners, or agents?

Are there currently any judgments, claims, arbitration or mediation proceedings or suits pending or outstanding against your company, officers, owners, or agents? Yes No
If yes, please explain:
Has your company ever failed to complete work awarded to it?

Has your company ever failed to complete work awarded to it? Yes No
If yes, please explain:
Has your company, its officers, owners, or agents ever been barred from bidding public work in North
Carolina?

Has your company, its officers, owners, or agents ever been barred from bidding public work in North
Carolina? Yes No
If yes, please explain:
SAFETY RECORD

List your company’s Experience Modification Rate (EMR), OSHA Incident Rate, and Lost Workday Case Incidence Rate for the past three years.
EMR (List present rate, last rate, year before rate)
OSHA Incident Rate (List present rate, last rate, year before rate)
Lost Workday Case Incident Rate (List present rate, last rate, year before rate)
Acknowledgement

Acknowledgement By submitting this document, you are acknowledging that all answers are true to the best of your knowledge. I also understand that any deliberate omissions or false information may be grounds for disqualification.
Company Name
Officer's Name Officer's Name First Last
Officer's Title

Company Information

Organization

Please take a few minutes to let us know what type(s) of work your firm is qualified to perform. Only check the work your own forces can accomplish. Do not check the work that you subcontract.

Work Experience

Project 1

Project 2

Project 3

Bonding

Insurance

LITIGATIONS/CLAIMS

SAFETY RECORD