Indian Preference Qualification Application Download Form NAME OF ENTERPRISE OR ORGANIZATION(Required) Phone(Required)FaxEmail(Required) Business Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is the business address your mailing address?(Required) Yes No Mailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have other locations?(Required) Yes No Please list the locations of all other offices (including temporary and part-time) Add RemoveOrganizationAre you a:(Required) private for-profit or non-profit company tribal organization Select one: Corporation Partnership Joint Venture Sole Proprietorship Other Date Established(Required) Place Established(Required) Dates organization changed or amended as to ownership and management(Required) Attach to this Application current organization documents (including where appropriate Articles of Incorporation and bylaws).(Required) Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 256 MB. Current OwnershipDate current ownership was established(Required) Current Ownership(Required)NamePut an "X" if enrolled in a federally recognized tribeAddressPhonePercent of ownership Add RemoveAttach to this application official evidence or record of enrollment of all owners who are enrolled members of federally registered tribes.(Required) Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 256 MB. How many employees do you currently have?(Required)Name any companies or individuals that provide management or administrative services to your company:(Required)Name who has made capital contributions to your company:(Required)Explain who will get your profit on this contract and what percentage:(Required)Who is your bank and the name and telephone number of the bank official you work with at the bank?(Required)What agency and what insurance company provides your insurance, and what is their phone number?(Required)Are you a construction company?(Required) Yes No What agency and what bonding companies provide your bid, performance and payment bonds, and what are their phone numbers?(Required)Explain who you will contract or subcontract more than 10% of your work to:(Required)If you are supplying goods, name companies that will provide you 10% or more of the goods to be provided under the contract you are seeking (and identify if they are 51% or more Indian owned and controlled by an enrolled member of a federally recognized tribal member):(Required)Past and Current PerformanceHave you or any owner of your entity had any of the following occur in the past 10 years and, if so, please explain with an attached narrative: filed bankruptcy or been petitioned into bankruptcy sued regarding a contract or payment of a contract sued regarding contract, performance or payment of a contract failed to complete a contract on time failed to finish a contract had a claim made on a bond provided on your behalf involved in arbitration regarding a contract or its performance had a contract terminated for cause denied Indian preference after seeking it debarred, suspended or other sanctions failed to properly pay a supplier, subcontractor, employee as required by contract any legal judgments entered against you any other incident involving performance of a contract where claims or disputes arose Attach to this Application appropriate narratives.(Required) Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 5 MB. Name other companies in businesses similar to what you now do that you and your owners have operated or owned in the last 10 years:(Required)List all tribes, tribally designated housing authorities, and Indian housing authorities that you have had a contract with in the past 10 years and the years you had the contract(s):(Required)ControlList all officers of your company and any Board members and identify if they are enrolled in a federally recognized tribe and if so, which tribe as well as what management duties they have:(Required)List the other top 10 management:(Required)If any of the above individuals have employment, positions or contracts with or interests in (including ownership) other companies, please so identify and explain, including the % or work time they spend in that position:Name the location of all temporary and permanent offices you have:(Required)If you are a construction company, list your core crew employees:(Required)What companies or individuals, if any, are mentoring or providing you assistance (including but not limited to loans, capital or staff) to develop as a company and explain on attached sheet:Disclose here and explain on an attached sheet any agreements or arrangements whereby some or all of your company is managed, administered or run in whole or in part by an individual(s) or company(s) not otherwise explained in this application:Disclose here and explain on an attached sheet any public or private agreements, or arrangements, other than those fully disclosed and explained elsewhere in this Application, whereby companies or individuals (i.e., service agreements, supplier contracts or subcontracting) received profit from you company:Upload any explanatory files for the above questions here. Drop files here or Select files Max. file size: 256 MB.
