Strategic Partner PRE-QUALIFICATION FORM Please submit this form via fax or email to: Chris Reese (614)873-0609—Fax [email protected] COMPANY INFORMATION. Company Name: Contact Person: Address: City: State: Telephone: Zip: Fax: After Hours Contact Number (REQUIRED): Federal ID#: Email Address: Web Site: SAFETY. Safety is very important at Staley. Please answer the following questions completely. Does your company have a current Safety Plan? Yes No **Note** Staley Inc., retains the right to request a copy of your safety plan and receive it in a timely manner. Has your firm had any OSHA citations, fines, or jobsite violations within the most recent three (3) years? *Yes No *If yes, please describe in detail on an attached sheet what occurred and what steps were taken by the company to prevent from happening in the future. What is your current EMR (Experience Modification Rating)? (REQUIRED IF ASSIGNED): What safety training do you provide your employees? (i.e. ladder, lock-out tag-out, MSDS, etc.) Customers may require that we be certified in the use of a lift and to have that certification on lifts. Do your electricians and/or technicians possess any lift certifications? (i.e. scissor lifts, boom lifts. Etc.) Yes No If so, what types? GENERAL INFORMATION. Geographical Area You Work In: (Example: DFW, State of Texas) (REQUIRED) Please Be Specific Union Company: *Yes No *If yes, please list affiliation: Year Business Started: Number of Techs: Number of Full Time Employees: Number of Electricians: Does your company do a pre-employment background check? Yes Do you require drug testing for employees? Yes Do you have BICSI certified techs? * Yes No No *If yes, how many? EXPERIENCE. What is your main line of work (Data, telecom, electrical)? What fields do you cover (fiber, cat5e, cat6, electrical, etc.)? No Number of Company Owned Vehicles: Do you have a 24x7x365 Service Group? Yes No Do you have Trained Fiber Optic Technicians? Yes Do you have CAT5e & CAT6 Testers? Yes No No What Kind? Do you have Fiber Testers? Yes No What Kind? Can Field Technicians Bend Pipe? Yes No Do you supply a list of minimum required hand tools for your technicians? * Yes *If yes, please attach list with this application. Please check the following items field technicians have onsite: Digital Camera? Yes Laptop? Yes Cell Phone? Yes No No No Machine Generated Labeler? Yes No Do you have experience with phone switches? *Yes No *If yes, please provide details (brand, option, etc.). Do you have experience with data switches? *Yes *If yes, please provide details: No No Do you have experience with security or CCTV? *Yes No *If yes, please provide details: Do you have experience with wireless? *Yes No *If yes, please provide details: List other areas of relative expertise: LEGAL ISSUES. Are there any judgments, claims, arbitration proceedings, or suits pending/out-standing against your firm or Its officer or principals? * Yes No *If yes, please provide a complete explanation on a separate sheet. Has your company filed any lawsuits or requested arbitration or mediation with regard to installation contracts within the last three (3) years? * Yes No *If yes, please provide a complete explanation on a separate sheet. Has your company or any of its Owners declared Bankruptcy in last 5 years? Yes Is your company owned or controlled by a parent or any other organization? * Yes *If yes, please describe on a separate sheet. PROJECT DEADLINES. Have you ever failed to complete a project? * Yes No If yes, provide details: Have you ever failed to complete a project on time? * Yes If yes, provide details: No No No REFERENCES. Provide three References (Owner, Architects, or General Contractors for work completed within the last 2 years): (REQUIRED) Project: Company: Address: Telephone: Fax: Your Contract $ Project: Company: Address: Telephone: Fax: Your Contract $ Project: Company: Address: Telephone: Fax: Your Contract $ SUPPLIER INFORMATION. Provide at least two suppliers. Supplier Name & Location: Contact Person: Telephone: Supplier Name & Location: Contact Person: Telephone: RATES. All fields are required. Electrician Hourly Rate: Data Technician Hourly Rate: Overtime Rate (if applicable): Typical Material Mark-Up: Per Diem Rate: Do you have a minimum hour policy? Yes Hotel Rate: Hourly Travel Rate: (or) Mileage Rate: Travel Policy Details: LICENSES. Contractor’s License (s) States and Numbers (if applicable): State: No: State: No: State: No: State: No: JUST CURIOUS. How did you hear about Staley Technologies? SIGNATURES. No I hereby certify that the above information is accurate, correct and true. X Completed By: (Name) (Title) ___________________________________________ (Signature) ___________________________________________ (Date) ___________________________________________