SUBCONTRACTORS | ATC Builders

Company Name

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DBA (if applicable):

Contact Information

Primary Contact Name & Title

Phone

Cell

Email

Website

Address

City/State/Zip

License Number

License Expiration

Date Form Completed:

Insurance & Bonding

Bond Rate:

Insurance Limits:

Current EMR

OSHA DART (Days Away, Restricted, or Transferred) Rate:

OSHA Total Case Rate (TCR):

Union Affiliation:

Bidding & Experience

Worked With (USCG, VA, Navy, Army/Air Force, Boeing, Other):

Private Medical Clients:

Diversity Certification Status (DBE, MBE, WBE, etc.)

Work Performed (Vendor, Subcontractor)

Scope of Work (list up to 8 trade codes/descriptions)

Cybersecurity Compliance (CMMC)

Is your company currently CMMC certified?

Yes

No

In Progress

Level of certification achieved

Level 1

Level 2

Level 3+

Certification Body Name

Certification Date (or expected)

Status or timeline toward compliance

Business & Tax Information

Legal Business Name

Primary Business Address:

City/State/Zip:

Contractor License Number:

WA L&I; Account Number:

WA UBI Number

WA Dept. of Revenue Tax Number

WA Employment Security Number:

Accounting Contact

Bookkeeper/Accountant Name & Title

Phone:

Fax:

Email

Acknowledgment

I certify that the above information is accurate and complete to the best of my knowledge and is provided in accordance with RCW 51.12.070.

Signed

Printed Name

Title:

Date

Advanced Technology
Construction

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