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Nassau County Office of Minority Affairs
Business Prequalification Form
all fields marked with an (
*
) are required.
Company Name:
*
Business Address:
*
City:
*
State:
*
Please Select...
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
District of Columbia
Guam
Puerto Rico
American Samoa
Northern Mariana Islands
U.S. Virgin Islands
Zip:
*
Business Phone:
*
Business Email:
*
Principal(s):
*
Name
Position
% Owned
Gender
Ethnicity
Male
Female
Prefer not to say
Black
Hispanic
Asian-Pacific
Asian-Indian
Non-Minority
Male
Female
Prefer not to say
Black
Hispanic
Asian-Pacific
Asian-Indian
Non-Minority
Male
Female
Prefer not to say
Black
Hispanic
Asian-Pacific
Asian-Indian
Non-Minority
Male
Female
Prefer not to say
Black
Hispanic
Asian-Pacific
Asian-Indian
Non-Minority
Male
Female
Prefer not to say
Black
Hispanic
Asian-Pacific
Asian-Indian
Non-Minority
Years in Business:
*
Please Select...
1
2
3
4
5
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100
Certification Type
(check all that apply)
:
*
MBE
WBE
MWBE
DBE
SDVOB
Briefly describe your company:
*
Are you affiliated with any unions?:
*
Please Select...
Yes
No
If Yes, Please List:
Have you worked on any Project Labor Agreement (“PLA”) projects?:
*
Please Select...
Yes
No
If no, are you interested in working on any PLA projects? :
*
Please Select...
Yes
No
Have you worked on any contracts with Apprenticeship Requirements?:
*
Please Select...
Yes
No
Are you bonded?
Please Select...
Yes
No
Annual Aggregate $:
Per Contract $:
What Types of Contracts, City, State or Federal Contracts have you worked for either as a prime or subcontractor? List at least three (3) contracts (within the last 3-5 years):
