Milton J. Womack, Inc. Pre-Qualification Form

We make every effort to respond to submissions as soon as possible. If your concern is immediate please call (225) 924-8050.

 

General Information

Company Name
Street
City/State
Zip
Contact Name Phone ( ) -
Email Address Fax ( ) -
LA License #: Federal Tax ID
 
License to Perform Work (Trades):
 
M/W/DBE (Minority Business Enterprise) Certification
 
Minority Disadvantaged Small Business
Woman Veteran Other
Certifying Agency Names:
 
 

Type of Business:

CORPORATION
  Date Incorporated: President:
LLC
  Date Established: Manager:
PARTNERSHIP
  Date of Organization: Manager:
INDIVIDUALLY OWNED
  Date Established: Owner:
OTHER
  Explain:
 

Insurance Coverage Type Limits:

Workmen's Compensation
General Liability
Excess / Umbrella Liability
Automobile Liability
 

Types of Work Projects:

Multi-Family Commercial Restaurants Education
Medical Governmental Civil Other
Average Contract $ Average Volume $
(Amount for projects last 3 years)(Annually for the last 3 years)
 

Work In Progress:

Job Name Owner or
GC Contact		 Contract Amount Scheduled
Completion Date
$
$
$
$
 

References:

Trade References: Project References:
 

Safety Experience Modifier:

  Year:      EMOD:
 

Plan Room:

Milton J. Womack, Inc., provides electronic media through Milton J. Womack’s FTP site and iSqFt Site. Is your company presently using or familiar with:

 
FTP Sites iSqFt Site Dodge / McGrawHill
 
 

All fields marked with * are required.

 

Main Office:

Milton J. Womack, Inc
8400 Jefferson Hwy.
Baton Rouge, LA 70809

(225) 924-8050 | phone
(225) 924-8085 | fax

 

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