Environmental Site Remediation Contractor Prequalification Form

Company Information

Company Name Address City State/Province Zip/Postal Code Country Contact Person Position/Title Phone Number Email Address

Company Profile

Year Established Type of Company (Corporation, Partnership, LLC, etc.) Number of Employees Geographic Areas of Operation

Services Offered

Select all that apply: Site Assessment
Excavation
Tank Removal
Hazardous Waste Management
Soil Remediation
Groundwater Remediation
Asbestos & Lead Abatement
Other (specify below)

Licenses & Certifications

List major environmental licenses, certifications, and registrations

Insurance Information

Coverage Types and Limits Insurance Carrier(s)

Project Experience

Provide details for three recent relevant projects:

Project Name	Location	Client	Scope of Work	Completion Date

Health & Safety

Do you have a formal Health & Safety Program? Yes No List any safety awards or recognitions Experience Modification Rate (EMR) - Last 3 Years

References

Provide two business references:

Company	Contact Name	Phone	Email

Additional Comments