Statement of Qualifications

1. General Information

Customer Name:

Address 1:

Address 2:

Contact Name:

Title:

Telephone Number:

Direct Dial:

Facsimile Number:

Web-site:

Email Address:

2. Organizational Structure/Key Personnel

2.1 How many years has your organization been in business as a Contractor?

2.2 How many years has your organization been in business under its present business name?

2.3 State(s) where your company holds a Business License:

2.4 State(s) where your company holds a Electrical License:

2.5 List of offices with addresses, phone/fax numbers and email addresses:

Address 1:
Address 2:
Phone Numbers:
Fax Number:
Email Address:
Address 1:
Address 2:
Phone Numbers:
Fax Number:
Email Address:

2.6 Indicate preferred geographic area(s) in which you want/expect to do business:

3. Experience/Capabilities

3.1 Energy Retrofit Technical Experience - Please check each area in which your company has experience:

Sign Maintenance
Lamp/Ballast Replacement - Fluorescent
Lamp/Ballast Replacement - HID
Fixture Replacement
Photo Cells/Occupancy Sensors
Reflectors
Delamping
Entire New System Install or Complete
Entire New System Replacement
New Circuits
Outdoor Lighting
Ballast Replacement Covers
Parking Lot Lighting

3.2 List the categories of work that your company normally performs with its own forces:

3.3 List the major projects your organization has in progress.

Name of Project:
Owner:
Contract Amount:
Percent Complete:
Scheduled Completion Date:
Reference Phone Number:

Name of Project:
Owner:
Contract Amount:
Percent Complete:
Scheduled Completion Date:
Reference Phone Number:

3.4 Please check all Market Segments in which your company has performed work:

Retail Facilities
Industrial Facilities
Healthcare Facilities
Government/Institutional Facilities
Commercial Office Facilities

4. Equipment Profiles

4.1 Please check all equipment that your company owns:

Scaffolding
Boom Trucks
Scissor Lifts
Boom Lifts
Bucket Trucks
Box Trucks
Storage - Please Describe

5. Risk Profile

5.1 Amount of largest project for which you have been bonded during the last two (2) fiscal years:

5.2 What is your Bonding Limit:

5.3 Who is your Bonding Agent:

5.4 Briefly describe the largest project completed in the last two (2) years. (Please include project description and contract amount - only include your contract amount if part of a larger project):

5.5 Have you ever failed to complete any work awarded to you? If yes, indicate client(s), reason(s) and date(s).

Yes -
No

5.6 Within the past five years, has your company filed for bankruptcy under the company's current or another name? If yes, please indicate date(s) and the current status of the proceeding.

Yes -
No

5.7 Has your organization filed any lawsuits or requested arbitration with regard to construction contracts within the last five years?

Yes
No

6. Safety

6.1 Does your company have a written safety program? If yes, please provide a copy for NES review.

Yes
No

6.2 Do your employees receive safety training? If yes, please provide the type(s) of safety instruction and the frequency.

Yes -
No

6.3 Please provide your company's Experience Modification Rate (EMR) for the past three years.

Year	EMR
Year	EMR
Year	EMR

6.4 How many work-related injuries has your company had in each of the last two years?

Year	# Injuries
Year	# Injuries

6.5 Do you have a Drug/Alcohol policy?

Yes
No

6.5a Do you perform random testing of your employees?

Yes
No

6.6 Do you presently have a Lockout/Tagout Policy and/or Procedure? If yes, please provide procedure.

Yes -
No

7. References

7.1 Please provide references of three customers for whom you have provided services/products in the past 12 months.

Company Name:
Address:
Nature of Service:
Project Size ($1,000s):
Key Contact:
Telephone Number:

Company Name:
Address:
Nature of Service:
Project Size ($1,000s):
Key Contact:
Telephone Number:

Company Name:
Address:
Nature of Service:
Project Size ($1,000s):
Key Contact:
Telephone Number:

8. Liability Requirements

If you are selected to be an approved NES Contractor, you will be required to meet minimum limits of Liability.

8.1 Please indicate the amount of coverage you presently have for the following categories:

Workers Compensation:
Employers Liability:

8.2 Comprehensive General Liability, including contractual -

Bodily Injury per person:
Bodily Injury per occurrence:
Property Damage per occurrence:
Personal Injury per occurrence:

8.3 Comprehensive Automobile Liability, including owned, non-owned and hired automotive equipment -

Bodily Injury per person:
Bodily Injury per occurrence:
Property Damage per occurrence:
Personal Injury per occurrence:
Commercial Umbrella Liability Insurance:

If selected as an approved Subcontractor for NES, a Certificate of Insurance naming National Energy Services, Inc. as Certificate Holder will be required.

9. Certification

I certify that all the information provided in this Statement of Qualifications is true and accurate to the best of my knowledge

Name of Officer:
Title:
Company Name:
Signature: (By typing here, I certify that all the information given is true and accurate)
Date:
Telephone Number:

Thank your for taking the time to complete this confidential questionnaire. This Statement of Qualifications will be used for internal purposes only.