Subcontractor Verification Form

SUBCONTRACTOR VERIFICATION FORM

Client Name:    Project:    Submission Date:

Personal & Company Information

Phone:    Email:    Mailing Address (if different):

Individual    Corporation    LLC    Partnership    Other:

Position / Scope of Work

Proposed Start Date:    Estimated Completion Date:    Contract Value / Estimated Amount: $

Licenses, Certifications & Safety

Issuing State:    Expiration Date:

Safety Training: OSHA 10/30    First Aid/CPR    Other:

Insurance & Bonding

Workers' Compensation Provided: Yes    Carrier:    Policy #:

General Liability Provided: Yes    Carrier:    Policy #:    Limit: $

Bonding Available: Yes    Bond Amount: $    Surety:

Tax, Classification & Compliance

Taxpayer ID (EIN/SSN):    W-9 Provided to Client: Yes

Independent Contractor    Subcontractor    Employee (if yes, provide explanation):

Are you currently debarred or suspended from contracting with any federal, state, or local government? No    Yes — If yes, explain:

Employment / Contract History

Most Recent Employer / Prime Contractor

Title / Role:    From:    To:

Previous Employer / Prime Contractor

Title / Role:    From:    To:

Education & Professional Training

Professional References (Provide three)

Reference 1

Phone:    Email:    Relationship:

Reference 2

Phone:    Email:    Relationship:

Reference 3

Phone:    Email:    Relationship:

Attachments Checklist

Certificate of Insurance: Attached    License Copy: Attached    Bond: Attached

Safety Plan: Attached    W-9 or Tax Document: Attached    References: Attached

Legal Disclosures & Authorizations

At-Will Employment Statement: If engaged by the client as a direct hire or subcontracted laborer, the subcontractor understands that any employment relationship may be at-will where permitted by law and may be terminated by either party at any time, with or without cause. This statement does not modify any written contract to the contrary between parties.

Equal Opportunity: The subcontractor affirms compliance with applicable equal opportunity and non-discrimination laws in performing services and in subcontractor employment practices. Subcontractor shall not unlawfully discriminate on the basis of protected characteristics.

Background Checks and References: By signing below the subcontractor expressly authorizes the client and its agents to contact prior employers, verify references, verify licenses and insurance, and to obtain consumer and/or criminal background checks where permitted by law. The subcontractor understands that adverse information may affect eligibility to perform work on the project.

Certification of Accuracy and Indemnity: The subcontractor certifies that all information provided herein is true, accurate and complete to the best of its knowledge. Subcontractor agrees to indemnify and hold harmless the client and its affiliates from any loss or liability arising from materially false statements, misrepresentations, or failures to disclose material information.

Drug and Alcohol Testing Policy: Subcontractor acknowledges that the client may require pre-employment and random drug and alcohol testing for individuals performing work on-site. Subcontractor agrees to comply with testing requirements for its employees and subcontracted personnel.

Safety and OSHA Compliance: Subcontractor warrants it will comply with all applicable safety regulations, site-specific safety rules, and will maintain required safety training for personnel assigned to the project. Failure to comply may result in removal from site and termination of agreement.

I certify that the information contained in this Subcontractor Verification Form is true and complete and that I authorize verification as stated above.

Applicant Certification & Authorization

I hereby certify under penalty of perjury that the foregoing statements and attached documentation are true and correct. I authorize the release of any information necessary to verify statements contained herein and to evaluate my qualifications for the scope of work. I agree to provide updated documentation upon request during the term of the contract or project.

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