CLE Lead Safe | Application for Contractors

Page 1

Thank you for your interest in working with CHN Housing Partners. We look forward to reviewing your application and engaging with you in our lead safe initiative. Please take a few minutes to fill out the following application so we can get started working together!

Please note before you begin that you cannot submit a completed application without the following documentation:

Insurance certificate

Workers Comp certificate

State of Ohio License (RA)

Sample of last completed Risk Assessment (RA)

EPA RRP License (Contractor)

Please have these documents ready when you start your application!

Page 2 | Company Information

Do you work for a company, or are you the sole proprietor?

Company

Company Name

Company Address

Address Line 1

Address Line 2

City

State

Zip Code

Company Phone

Email

Sole Proprietor

Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Page 3 | Company Information, continued.

Business Owner's Name

Which of the following describes the business?

Primary Business Contact

Contact Name

Title

Cell Phone

Email

Page 4 | Company information, continued.

Should be in business for at least one year

Number of years in business

Year established

How many employees/crew members do you have?

How many years of experience do you have in direct construction/renovation?
At least two years of experience required

Are you or your company in good standing with the State of Ohio?

Please list every municipality you are registered to do business in.

Please list the name of your or your company's insurance company.

Please attach a copy of your General Liability Insurance certificate with minimum coverage of $2,000,000 aggregate and $1,000,000 per occurrence. If approved, you must name CHN Housing Partners and CHN Housing Capital as additional insured.

Please attach a copy of your EPA RRP training certificate.

Please attach a copy of your EPA Lead Safe Firm Certificate.

Please attach your current Bureau of Worker's Compensation certificate, if applicable.

Page 5 | Criteria

Please list the last three (3) jobs you and/or your company have preformed.

Past Job information

Customer Name

Job Address Line 1

Job Address Line 2

City

State

Postal Code

Describe project preformed

Contract Amount $

Contact person name

Contact person phone #

Page 6 | Certification

I certify that my business has the financial ability to carry jobs for a period of 45-60 days.

I certify that my business will maintain a clean and safe worksite and provide excellent customers service to the property owner and this program.

I certify that my business will preform the work in a lead safe manor.

I certify that my business is a Drug Free Workplace.

I certify that neither any owner(s), any employees, or any independent consultants of the company have been convicted of a violent felony within the past seven (7) years.

I certify that no conflicts of interest exist with my business. I further attest that no officer, employee or board members of CHN Housing Partners or its affiliates has any connection to, or any direct or indirect interest in my company.

Page 7 | Sign and Sumbit

Typing your name in the box below will serve as your electronic signature and as agreement to the following:

I certify that my answers contained in this online application are true and complete to the best of my knowledge.
If this application is approved, I understand that any false or misleading information in my application may result in disqualification from the program.

Electronic Signature

Date