Strategic Partner Pre-Qualification Form Company InformationCompany Name:*Contact Person:*Address:*City:*State:*Zip:*Telephone:*Fax:After Hours Contact Number:*Federal ID#:Email Address:* Email Address for Service Request:* 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 what occurred and what steps were taken by the company to prevent from happening in the futureWhat 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 InformationPlease list all states and counties in which you work. Please Be Specific* Union Company: *Yes No *If yes, please list affiliation:Year Business Started: Number of Full Time Employees:Number of Techs:Number of Electricians:All Staley partners are required to perform drug testing and background checks. Does your company do a pre-employment background check? Yes No Do you require drug testing for employees? Yes No Do you have BICSI certified techs? *Yes No *If yes, how many?ExperienceWhat is your main line of work (Data, telecom, electrical)?What fields do you cover (fiber, cat5e, cat6, electrical, etc.)?Number of Company Owned Vehicles:Do you have a 24x7x365 Service Group? Yes No Do you have Trained Fiber Optic Technicians? Yes No Do you have CAT5e & CAT6 Testers? Yes 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 No *If yes, please detail list below.Please check the following items field technicians have onsite:Digital Camera? Yes No Laptop? Yes No Cell Phone? Yes 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 No *If yes, please provide details:Do you have experience with security or CCTV? *Yes No *If yes, please provide details:Do you have experience with wireless (installations, coverage surveys, etc.)? *Yes No *If yes, please provide details:Do you have any experience in Access Control (wiring, devices, programming, etc.)?: *Yes No *If yes, please provide details:Legal IssuesAre 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 below.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 below.Has your company or any of its Owners declared Bankruptcy in last 5 years? Yes No Is your company owned or controlled by a parent or any other organization? *Yes No *If yes, please describe below.Project DeadlinesHave you ever failed to complete a project? *Yes No *If yes, provide details:Have you ever failed to complete a project on time? *Yes No *If yes, provide details: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 Amount:*Project:*Company:*Address:*Telephone:*Fax:*Your Contract Amount:*Project:*Company:*Address:*Telephone:*Fax:*Your Contract Amount:*Rates All fields are required.Electrician Hourly Rate:*Data Technician Hourly Rate:*Security Technician Rate:*Overtime Rate (if applicable):*Typical Material Mark-Up:*Per Diem Rate:*Do you have a minimum hour policy?* *Yes No If yes, please describe: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:Please submit your current Certificate of Insurance (COI).Just CuriousHow did you hear about Staley Technologies?Signatures I hereby certify that the above information is accurate, correct and true.Name:Title:Date: UntitledPhoneThis field is for validation purposes and should be left unchanged.