Request for Qualifications Form- Registered Contractors List

Please fill out the Request for Qualifications Form- Registered Contractors List.

Business Information

Complete Legal Business Name*

Business Contact*

First Name Last Name

Business Address*

Street Address Address Line 2 City State ZIP Code

Business Contact Phone*

Business Contact Email*

Additional Contractor Information (Optional)

Phone

Email

Business Form*

Corporation
Limited Liability Company
General or Limited Partnership
Sole Proprietorship

Business Activities

Please list the 2022 North American Industrial Classification System (NAICS) codes most closely associated with the business’s primary activity.

Please list any other 2022 North American Industrial Classification System (NAICS) codes associated with the business’s secondary activities, if any. NOTE: The inclusion of additional NAICS codes is not required, but may assist Port KC in providing more targeted contracting opportunities to those businesses on the Registered Contractors List.

The 2022 North American Industrial Classification System (NAICS) codes can be found at https://www.census.gov/naics/.

Business Profile

Operations*

Local
Regional
National

Local Business Address*

Number of Staff Employed at Local Office*

Provide a brief Contractor history*

Indicate previous work experience with Port KC*

Is your business a Certified Minority Business Enterprise (MBE)? If yes, please append a copy in your submittal.*

YES
NO

File

Max. file size: 50 MB.

Is your business a Certified Women Business Enterprise (WBE)? If yes, please append a copy in your submittal.*

YES
NO

File

Max. file size: 50 MB.

Other certifications? If yes, please append a copy in your submittal.*

YES
NO

File

Drop files here or

Max. file size: 50 MB.

I certify to obtain and/or maintain insurance at the following levels:*

(a) Commercial General Liability Insurance with a limit of $1,000,000 per occurrence and $2,000,000 aggregate. (b) Commercial Automobile Liability Insurance with a limit of $1,000,000 per occurrence, covering owned, hired, and non-owned automobiles. (c) Worker’s Compensation Insurance in accordance with statutory requirements and Employer’s Liability Insurance with limits of not less than $100,000 for each occurrence, $500,000 disease-policy limit, and $100,000 disease-each employee. (d) Professional Liability Insurance with limits of not less than $2,000,000 per claim and annual aggregate.

YES
NO

Professional References

Professional Reference #1 Name*

Company*

Relationship*

Business Address*

Street Address Address Line 2 City State ZIP Code

Phone

Professional Reference #2 Name*

Company*

Relationship*

Business Address*

Street Address Address Line 2 City State ZIP Code

Phone

Professional Reference #3 Name*

Company*

Relationship*

Business Address*

Street Address Address Line 2 City State ZIP Code

Phone

Business Qualifications

Provide a list of key permanent staff members, including name, job description, titles, relevant educational and professional experience.*

Please describe any violations/citations and pending litigation which involve the Contractor and/or its principals.*

Disclaimer & Signature

I certify that my answers are true and complete to the best of my knowledge. If this application leads to contract work with Port KC, I understand that false or misleading information in my application may result in my release.*

YES