CONTRACTOR PREQUALIFICATION Contractor Prequalification GENERAL INFORMATION Company Name: * Street Address: * Street Address: Street Address: Street Address: City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Parent Company (if applicable): Parent Company Address (if applicable): Parent Company Address (if applicable): Parent Company Address (if applicable): Parent Company Address (if applicable): City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Type of Business: * Sole Proprietorship Partnership Corporation Describe the services offered: * How many years has the company been in business? * How many years has the company been operating under current management or ownership? * Approximate Revenue Last Fiscal Year: CONTACT Primary Contact: * Title: * Email Address: * Phone Number * GOOD STANDING & RELATIONSHIP Are there any judgments, claims or suits pending or outstanding against your company? * Yes No Are you now, or have you ever been, involved in any bankruptcy or reorganization proceedings? * Yes No Have you performed work for Rassaun Services Inc. in the past? * Yes No HEALTH & SAFETY - KEY METRICS Have you received a Ministry of Labour stop work order, or equivalent, in the last three years? * Yes No Describe Incident: * Number of Medical Aid (No Lost Time) Incidents This Year: * Number of Medical Aid (Lost Time) Incidents This Year: * Number of Fatalities This Year: * Number of Medical Aid (No Lost Time) Incidents Last Year: * Number of Medical Aid (Lost Time) Incidents Last Year: * Number of Fatalities Last Year: * Number of Medical Aid (No Lost Time) Incidents 2 Years Ago: * Number of Medical Aid (Lost Time) Incidents 2 Years Ago: * Number of Fatalities 2 Years Ago: * HEALTH & SAFETY - PROGRAM & PROCEDURES Select the programs & procedures that are included in the company health & safety program. Lockout/Tagout * Yes No Confined Space Entry: * Yes No Working At Heights: * Yes No Hot Work: * Yes No Personal Protective Equipment: * Yes No Powered Mobile Equipment: * Yes No Hand Tools/Small Power Tools: * Yes No Electrical Safety/Arc Flash: * Yes No Accident/Incident Reporting: * Yes No WHMIS: * Yes No HEALTH & SAFETY - INSPECTIONS & AUDITS Do you conduct health & safety inspections? * Yes No Inspection Frequency: * Do you review/audit your health & safety program? * Yes No Do you have a corrective action process for addressing individual health & safety performance deficiencies? * Yes No CONTRACTOR AGREEMENT Download our contractor health & safety agreement from here, sign, and upload below. Signed Agreement: * Drop a file here or click to upload Choose File Maximum upload size: 516MB WSIB Please upload your WSIB records. WSIB: * Drop a file here or click to upload Choose File Maximum upload size: 516MB Insurance Please upload your insurance documents. Insurance: * Drop a file here or click to upload Choose File Maximum upload size: 516MB Form 1000 Please upload a Form 1000, if applicable. Form 1000: Drop a file here or click to upload Choose File Maximum upload size: 516MB Program Manual Please upload your Health & Safety program. Program Manual: * Drop a file here or click to upload Choose File Maximum upload size: 516MB Hazard Identification Form Please upload your primary hazard identification form. This is sometimes called a field level hazard assessment (FLHA) or a job hazard assessment (JSA). Hazard Identification Form: * Drop a file here or click to upload Choose File Maximum upload size: 516MB Additional Documents Upload any additional documents. Additional Documents: Drop a file here or click to upload Choose File Maximum upload size: 516MB If you are human, leave this field blank. Submit
