DCAS CCMP Tier 1 Application

Step 1 of 8

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SECTION 1: GENERAL INFORMATION

Legal Name of the Applicant Firm

Federal EIN or Owner’s SSN

Business Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Office Phone

Cell Phone

Email Address

Company Website

Has the applicant firm changed its address in the last five years? If so, list each prior address.

Does the applicant firm perform business under any other name, Doing Business As (DBA)?

Yes

N/A

If yes, what is the DBA name?

Has the applicant firm done business under any other name, Formerly Known As (FKA)?

Yes

N/A

If yes, what is the FKA name?

Does the applicant firm have a PASSPort account that is in "Filed" status?

Yes

SECTION 2: BUSINESS ORGANIZATION & HISTORY

Month and Year Applicant Firm was Founded

Type of Legal Entity

(Sole Proprietor, LLC, Corporation, General Partnership, Limited Partnership, Joint Venture)

Was the applicant firm legally created in NYS?

Yes

Does the applicant firm have Authority to do Business in NYS?

Yes

If no, which state?

If no, provide Certificate of Authority from the New York Department of State (NY DOS)

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Max. file size: 256 MB.

Please upload your certificate of incorporation or legal formation documents

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Max. file size: 256 MB.

Does the applicant firm have any trade or business-related licenses?

Yes

N/A

Is the license issued to a specific individual in the applicant firm?

Yes

N/A

Provide the license holder's name

Upload Business and/or Individual Related Licenses (front and back images)

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Max. file size: 256 MB.

City and State Certifications (check all that apply)

NYS MBE Certification

NYS WBE Certification

NYC MBE Certification

NYC WBE Certification

NYC EBE Certification

NYC LBE Certification

PANYNJ MBE

PANYNJ WBE

PANYNJ SBE

NYS SDVOB

Other

(Other) Please specify

Upload NYS and NYC Certifications

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Max. file size: 256 MB.

Does the Applicant Firm participate in a union agreement?

Yes

N/A

Provide the name of the union

Is the applicant firm already registered or awaiting determination with the New York State Contractor and Subcontractor Registry? https://dol.ny.gov/contractor-and-subcontractor-registry-landing

Yes

Awaiting Determination

Is the firm participating in any mentoring program?

Yes

N/A

Provide the name of the mentoring program

Dates of Participation

List below the name of each person, other than the owner, who is a key person within the Applicant Firm and, for each person, provide the information specified below.

A “key person” is any of the following, who is NOT AN OWNER
• a director, officer, member or owner
• any person in a position to significantly control and direct the firm’s overall operations or financial decisions.
• any person in a position to significantly control and direct the firm’s performance of any project
• Signatories to bank accounts
• Holders of licenses necessary for the Applicant Firm to engage in a building trade

List all key persons

Name

Business Title and Role

Home Address

Home Phone

Commencement Date in Current Title

Professional Licenses, Certifications, Trade Qualifications and affiliations

List all Owners

Name

Address

Title

% Ownership

If the owner(s) of the applicant firm has ownership interest in ANY OTHER construction industry firm during the last ten (10) years, answer the following:

Name of the owner:

Name of the firm

% Ownership

Is the applicant firm owned by any other entity? (i.e. business, investment firm, etc.)

Yes

If yes, what is the name of that entity?

Has the owner of the applicant firm served as a key person for any other construction industry firm?

Yes

If yes, provide

Name of owner

Name of firm

Address of firm

Role / Title

Start / End Dates

Has the applicant firm completed any NYC construction contracts?

Yes

If yes, provide

Contract No

Contracting Agency

Contract Description

Work performed as Prime / Sub

Contract Amount or Subcontract Amount $

Does the Applicant Firm have experience managing Prevailing Wage Contracts?

Yes

Does the Applicant Firm have experience within a Project Labor Agreement?

Yes

Enter the number or approximate number of Applicant Firm personnel for each type of employment.

Full -time IRS W-2

Part-time IRS W-2

1099 Contractors

Is any owner a current or former NYC employee?

Yes

If yes, provide

Agency

Title

Employment Dates

Is any owner a current or former TDX employee?

Yes

If yes, provide

Title

Employment Dates

Majority Owner

Name

Title

Phone

Gender

Ethnic Group

Asian Pacific: Asian-Pacific American includes persons whose origins are from Japan, China, Taiwan, Korea, Burma (Myanmar), Vietnam, Laos, Cambodia (Kampuchea), Thailand, Malaysia, Indonesia, the Philippines, Brunei, Samoa, Guam, The U.S. Trust Territories of the Pacific Islands, Macao, Fiji, Tonga, Kiribati, Juvalu, Nauru, Federated States of Micronesia, or Hong Kong.

Black: Black American includes persons having origins in any of the Black racial groups of African descent.

Caucasian: Caucasian American includes persons having European ancestry.

Hispanic: Hispanic American includes persons of Mexican, Puerto Rican, Cuban, Dominican, Central or South American, or other Spanish or Portuguese culture or origin, regardless of race.

Native American: Native American includes persons who are American Indians, Eskimos, Aleuts, or Native Hawaiian.

Subcontinent Asian: Subcontinent Asian includes persons whose origins are from India, Pakistan, Bangladesh, Bhutan, the Maldives Islands, Nepal, Middle Eastern, or Sri Lanka.

If owners have equal shares, include information for each owner.

U.S. Citizenship

U.S. Citizen

Permanent Resident

SECTION 3: PROJECTS

Project # 1

Project Name

Owner

Address

Contract #

Description

Prime/Sub

$ Amount

Start Date

End Date

Project # 1 Reference

Reference Contact Name

Reference Contact Title

Reference Contact Agency

Reference Contact Phone

Reference Contact Email

Did your firm perform as the Prime or Sub?

Project # 2

Project Name

Owner

Address

Contract #

Description

Prime/Sub

$ Amount

Start Date

End Date

Project # 2 Reference

Reference Contact Name

Reference Contact Title

Reference Contact Agency

Reference Contact Phone

Reference Contact Email

Did your firm perform as the Prime or Sub?

Project # 3

Project Name

Owner

Address

Contract #

Description

Prime/Sub

$ Amount

Start Date

End Date

Project # 3 Reference

Reference Contact Name

Reference Contact Title

Reference Contact Agency

Reference Contact Phone

Reference Contact Email

Did your firm perform as the Prime or Sub?

Project # 4

Project Name

Owner

Address

Contract #

Description

Prime/Sub

$ Amount

Start Date

End Date

Project # 4 Reference

Reference Contact Name

Reference Contact Title

Reference Contact Agency

Reference Contact Phone

Reference Contact Email

Did your firm perform as the Prime or Sub?

SECTION 4: FINANCIAL

Upload: Financial Statements (3 most recent years)

Drop files here or

Max. file size: 256 MB.

Upload: Tax Returns (3 most recent years) Federal and State

Drop files here or

Max. file size: 256 MB.

Do all owners have a Personal Net Worth under $3.5M?

Yes

Upload: Owner(s) Individual Income Tax Returns (2 most recent years) Federal and State

Drop files here or

Max. file size: 256 MB.

List All Business Bank Accounts

Name

Type

Bank

Address

Signatories

Upload: 3 Most Recent MONTHS Bank Statements (include canceled checks if applicable)

Drop files here or

Max. file size: 256 MB.

Does the firm have bonding capacity?

Yes

If yes, provide

Surety Name & Address

Agent /Broker Name and Phone #

Indemnitor Info

Single Capacity

Aggregate Capacity

Available Capacity

Does the firm have a line of credit?

Yes

If yes, provide

Institution Name

Guarantor Info

Single & Aggregate Credit Limit

Has the firm ever defaulted on a loan?

Yes

If yes, provide details

SECTION 5: INSURANCE, OPERATIONS, AND SAFETY

Does the firm have General Liability Insurance?

Yes

Does the firm have Workers' Comp Insurance?

Yes

Does the firm have Commercial Auto Insurance?

Yes

Does the firm have Excess Liability Insurance?

Yes

Does the firm have Hazardous Liability Insurance?

Yes

Upload: Insurance Certificates / Coverage Summary

Drop files here or

Max. file size: 256 MB.

Any personal or workers' comp claims in past 5 years?

Yes

If yes, provide

Type

Insurer

Date

Claimant

Amount

Disposition

Summary

Any OSHA violations in last 5 years?

Yes

Violations by Year and Category (Serious, Willful, etc.)

Any other business-related violations in last 5 years?

Yes

If yes, provide

Describe Violation

Disposition

Year

Name & Title of Highest Ranking Safety Employee

Any current safety certifications held by employees?

Yes

Upload: Safety Certifications, Licenses or Training Proof (OSHA 30 HR or better should be issued within the last 5 years)

Drop files here or

Max. file size: 256 MB.

Current and Prior Year

EMR

OSHA Recordables

Days Away

Fatalities

Upload: EMR or OSHA 300 Logs (For most recent 2 years)

Drop files here or

Max. file size: 256 MB.

SECTION 6: INTEGRITY

Filed for insolvency or bankruptcy?

Yes

Explain Insolvency or bankruptcy

Been a debtor in a bankruptcy case?

Yes

Explain debtor in a bankruptcy case

Have any unpaid Business or Personal Income Tax due in any jurisdiction?

Yes

Explain unpaid Tax due in any jurisdiction

Had liens filed against it/them?

Yes

Provide Lien details and description

Had judgments or injunctions filed against it/them?

Yes

Provide Judgment/Injunction details and description

Changed construction license numbers?

Yes

Explain about construction license numbers

Been involved in litigation, arbitration, or mediation?

Yes

Explain involvement in litigation, arbitration, or mediation

Any unpaid Environmental Control Board (ECB) Violations?

Yes

Explain unpaid Environmental Control Board (ECB) Violations

Changed ownership, control, or senior management?

Yes

Explain changes in ownership, control, or senior management

Convicted of violating any U.S. Labor Laws?

Yes

Explain Convicted of violating any U.S. Labor Laws

Been convicted of a felony or other criminal conduct?

Yes

Explain felony or criminal conviction/conduct

SECTION 7: CONTRACT PERFORMANCE AND CLAIMS

Failed to complete a contract?

Yes

Explain contract failure

Terminated for cause from a project?

Yes

Explain termination for cause

Had a claim made for non-compliant work or failed warranty?

Yes

Explain non-compliance work or failed warranty claim

Been suspended, debarred, or disqualified from bidding?

Yes

Explain suspension, debarment, or disqualification from bidding

SECTION 8: CERTIFICATION OF APPLICATION

Name of Certifier

Title of Certifier

Date of Certification

To be considered for prequalification into the program, please complete the application questions. If you have any questions about the application process or the program, feel free to contact us by: Email: [TBD] | Telephone: [TBD]

SECTION 1: GENERAL INFORMATION

SECTION 2: BUSINESS ORGANIZATION & HISTORY

SECTION 3: PROJECTS

SECTION 4: FINANCIAL

SECTION 5: INSURANCE, OPERATIONS, AND SAFETY

SECTION 6: INTEGRITY

SECTION 7: CONTRACT PERFORMANCE AND CLAIMS

SECTION 8: CERTIFICATION OF APPLICATION

The Conference Center Bulletin

To be considered for prequalification into the program, please complete the application questions.

If you have any questions about the application process or the program, feel free to contact us by: Email: [TBD] | Telephone: [TBD]