Contractor's Page

Contractor's Meet and Greet dates

ghp_contractorapp_final_.docx
File Size:	43 kb
File Type:	docx

Download File

GHP INDEPENDENT CONTRACTOR APPLICATION

SECTION A – BUSINESS INFORMATION
Please provide the legal name which appears on your business license, or under which your business will be operating as an independent contractor for GHP. Please further detail the contact information where you or your representative agent can be reached.

* Indicates required field

Full Business Name *

Type of Identity (e.g., individual, corporation, LLC, , etc.) *

Business Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

Business Street Address *

Line 1

Line 2

City

State

Zip Code

Country

Business Phone Number *

Business Fax Number *

Busines Email Address *

SECTION B – APPLICANT INFORMATION
Please provide the full legal name and address for the individual who is applying to contract with GHP, and who will serve as the point of contact for GHP projects.

Applicant's Full Name *

First

Last

Date of Birth *

Social Security Number *

Residence Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Alternate Phone Number *

Applicant's Email Address *

Title or Position *

Owner Partner Responsible Managing Employee

SECTION C – CONTRACTOR LICENSE INFORMATION
Please provide a detailed account of the highest class of license to contract that you or your business entity hold to do business in the Commonwealth of Virginia or Gloucester County, and the name and contact information for the qualifying individual(s) listed on that license. If you or your organization hold multiple licenses to contract, please list any additional, relevant licenses under “SECTION F – ADDITIONAL INFORMATION”

Classification of License *

Issuing Entity *

License Number *

Date Issued/Renewed *

Qualifying Individual's Full Name *

First

Last

Date of Birth *

Social Security Number *

Qualifying Individual's Address *

Line 1

Line 2

City

State

Zip Code

Country

Qualifying Individual's Phone Number *

Qualifying Individual's Email Address *

SECTION D – INSURANCE INFORMATION
Please provide the required information on any general liability insurance policies that you or your organization currently hold for the purposes of conducting business in the Commonwealth of Virginia and/or Gloucester County.

Name of Insurer *

Type of Insurance/Coverage *

Date Issued *

Date Renewed *

Amount of coverage (e.g., $1,000,000.00 in general liability) *

Insurer's Business Address *

Line 1

Line 2

City

State

Zip Code

Country

Name of Insurance Representative *

First

Last

Insurer's Phone Number *

Insurer's Email *

SECTION E – REQUIRED APPLICATION QUESTIONS
All questions in this section must be answered. Questions pertain to the applicant listed in Section B of this application form, and any and all employees of the business or applicant who are intended to work on the proposed contract for GHP. If “yes” in response to any question, the applicant must attach a separate sheet with a detailed explanation for each situation.

NOTE: Answering “yes” to any of these questions DOES NOT automatically disqualify you from bidding on GHP projects. These questions are required by GHP to meet due diligence standards and uphold the professional responsibilities of our organization.

To the best of your knowledge, is anyone listed on this application named in or responsible for any unsatisfied final judgements, liens, and/or claims against any bond or cash deposit pertaining to a construction project?

If “yes” for this question, you are required to attach a statement identifying all judgements (pending or on record), liens, past due unpaid bills, claims, or suits and a detailed explanation of the situation. Include the names and addresses of the parties involved. If the obligation was or is being discharged in bankruptcy, attach a copy of the bankruptcy filing and a copy of the creditors list. *

Has anyone listed on this application ever been convicted of or entered a plea of guilty or nolo contendere to any felony or misdemeanor involving moral turpitude (I.E., lying, cheating, or stealing) in the united states?

Note: Convictions that were later expunged from the records of the court or set aside must be disclosed. However, some convictions should not be disclosed, including:

Convictions that were adjudicated in juvenile court;
Charges that were dismissed as a result of successful completion of a deferred entry of judgement program (diversion program).

If “yes” for this question, you are required to attach a statement disclosing the nature of the conviction and explain the acts or circumstances that resulted in the plea/conviction(s). Note: Gailure to report a disclosable plea/conviction may be grounds for the denial of your application. *

To the best of your knowledge, has anyone on this application ever received a citation from the Virginia department of professional and occupational regulation or had a contractor license or other professional or vocational license or registration denied, suspended, revoked, or otherwise disciplined by the commonwealth of Virginia or elsewhere (I.E., other U.S. State, U.S. Territory, Agency of the Federal Government, etc.)?

For the purposes of this question, “disciplined” is an administrative action that resulted in a restriction or penalty being placed on any license you have or have possessed, such as a revocation, suspension, probation, or reprimand. If “yes” for this question, you are required to attach a statement detailing the events leading to this action. *

Direct supervision and control over construction operations, includes any one or a combination of the following activities: supervising construction, managing construction activities by making technical and administrative decisions, checking jobs for proper workmanship, or direct supervision on construction job sites. Will you, as the applicant, perform one or more of these duties.

NOTE: This question must be answered by the applicant and/or qualifying individual listed on the contractor’s license. *

SECTION F – ADDITIONAL INFORMATION
Where the space available for answers to questions in SECTION A through SECTION E is insufficient for a full, detailed response, please list additional information in this section.

Additional Information *

SECTION G – CERTIFICATION OF ACCURACY
This section must be read by the applicant responsible for the contents of the GHP Independent Contractor Application

I certify, under the penalty of perjury under the laws of the Commonwealth of Virginia that all statements, answers, and representations made in this application, including all supplementary statements attached hereto, are true and correct, and that I have reviewed the entire contents of this application. I further recognize that, should any information in this application be incomplete or incorrect, GHP reserves the right to disqualify my business or organization from bidding on future contracts or projects.

Submit

Contractor's page

GHP INDEPENDENT CONTRACTOR APPLICATION

Contact Us