BART SBSS STATEMENT OF QUALIFICATIONS INTAKE FORM

GENERAL INFORMATION

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* 1. COMPANY INFORMATION

COMPANY NAME

COMPANY ADDRESS

COMPANY ADDRESS 2

COMPANY CITY

COMPANY STATE

COMPANY ZIP/POSTAL CODE

WEBSITE

COMPANY PHONE NUMBER

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* 2. CONTACT INFORMATION

NAME

EMAIL ADDRESS

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* 3. BUSINESS LOCATION(S)?

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* 4. LENGTH OF TIME IN BUSINESS

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* 5. HOW IS YOUR BUSINESS SET UP?

SOLE PROPRIETOR

S CORP

C CORP

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* 6. TOTAL # OF EMPLOYEES

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* 7. DO ANY EMPLOYEES BELONG TO A UNION?

YES

NO

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* 8. CONTRACTOR LICENSES NO.

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* 9. LIST OF SERVICES YOUR COMPANY PROVIDES

SERVICES 1

SERVICES 2

SERVICES 3

SERVICES 4

SERVICES 5

SERVICES 6

SERVICES 7

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* 10. Type of Company?

PROFESSIONAL SERVICES

CM

CONTRACTOR

GOODS/SERVICES

OTHER (PLEASE SPECIFY)