APPLICATION FORM 4M & 4MA

APPLICATION FORM 4M & 4MA APPLICANT ID Office use only APPLICATION FEE: $170 CONTRACTOR PREQUALIFICATION BUILDING CONSTRUCTION PROJECTS (Edition 2007) GENERAL BUILDING CONTRACTOR AND TRADE/SUBCONTRACTOR CATEGORY 4M $50,000 to $250,000 General Building Contractor Trade Contractor CATEGORY 4MA Less than $50,000 Trade Contractor Asbestos Removal Only Return to: The Registrar of Prequalification Building Management Department for Transport, Energy and Infrastructure Level 2 211 Victoria Square Adelaide 5000 GPO Box 967 Adelaide 5001 Telephone (08) 8226 5209 Facsimile (08) 8226 5588 Email: buildingmanagement@saugov.sa.gov.au Revised Februry 2009

DEFINITIONS Building: Any roofed structure enclosing space and intended for use as a shelter (for people, animals or property) or for recreational, industrial, commercial or other functions. General Building Contract: A general building contract is a contract for concurrent construction work completed generally within the boundary of one specific site and excludes repetitive construction work spread over several sites and/or varying periods of time. General Building Contractor: An entity, which contracts with the South Australian Government to construct a building and usually engages subcontractors to carry out specific trade work relevant to the contract. Trade Contractor: An entity, which contracts with the South Australian Government to carry out specific trade work (eg bricklaying, ceiling fixing / partitions). Sub Contractor: An entity, which contracts with the General Building Contractor to carry out specific trade work. SYSTEM OVERVIEW For information on general operation of the Contractor Prequalification system for Building and Construction projects and detailed benchmark criteria refer to the following documents included in the Application Kit: Contractor Information Performance Assessment Other documents referenced in this application form are included in the Application Kit. Revised January 2007

Part 1 - Contractor Details A1 What is the trading name of the contractor seeking prequalification? A2 What is the legal status of the contracting business? Dependent upon the structure of the business more than one descriptor may apply. Cross all boxes which apply Incorporated Company... Australian Company Number (A.C.N.)? Sole Proprietorship... Partnership... Trust... Registered Business... Australian Registered Business Number (A.R.B.N.)? A3 What is the contractor s Australian Business Number (A.B.N.)? A4 What is the contractor's Building Work Contractors (or PGE) Licence Number? Licence No Expiry Date / / Conditions or Restrictions A5 What is the business address of the contractor seeking prequalification? Address Suburb Postcode Telephone No. E-mail address Fax No. Website A6 What is the postal address of the contractor seeking prequalification? (If different from A5) Address Suburb Postcode A7 Complete the following table by listing all directors (if a company) and all partners (if a business). FIRST NAME (IN FULL) MIDDLE NAMES (INITIALS) SURNAME Revised January 2007 1

A8 and telephone number of person who can be contacted if further information is required. FIRST NAME (IN FULL) SURNAME Telephone No. Mobile No. E-mail address Facsimile No. Part 2 Work/Trade Types and Locations To be considered for prequalification, the contractor seeking prequalification must be able to demonstrate experience on similar contracts. Refer to Part 3 for details. Contractors can nominate for registration in multiple categories appropriate to their business. For each work/trade type, applicants will be assessed against the relevant prequalification criteria. Registration will be granted in each work/trade type. A9 Does the contractor seek registration as a: General Building Contractor?... Trade/Sub Contractor Category 4M?... Trade/Sub Contractor Category 4MA?... A10 Trade/Sub Contractor only, cross boxes for all work / trade types for which prequalification is sought. CATEGORY LICENCE NUMBER WORK/TRADE TYPE 4M 4MA ASBESTOS Asbestos Removal... Aluminium Framing / Glazing... Bricklaying / Stonemasonry... Carpentry (1 st & 2 nd Fix)... Ceilings / Partitions... Civil Work... (Pavements, Excavations for Building Construction) Concrete Construction/Reinforcing/Formwork Demolition... SECURITY AGENT Electrical / Electronic (incl Security).... Fire Protection... Revised January 2007 2

Joinery... Lifts, Escalators... Mechanical.... (General, Mechanical Services, Air Conditioning) Plumbing... Roofing... Structural Steelwork... A11 Cross all the locations in which the contractor is prepared to work. South Australia - all areas excluding Far North... Adelaide city and metropolitan area... Fleurieu Peninsula/Kangaroo Island... South East area... Riverland... Murraylands... Mid North including Yorke Peninsula... Port Pirie/Port Augusta/Whyalla... Eyre Peninsula area/west Coast area... Far North... Previous experience in Far North Yes No Part 3 - Technical Capability Technical capability is measured by the Contractor's experience in undertaking relevant projects (A14) and Referee reports (Refer Part 10) A12 Provide the number of employees. Include - Permanent full-time and part-time employees and permanent casuals. Exclude - Contract employees Number of Employees A13 How many contracts were awarded to the Contractor during the last full financial year: Over $50,000 Less than $50,000 General Building Contractor Trade / Sub Contractor (Asbestos Removal only) A14 How many years experience does the Contractor have? (Only include experience of the business - not individual directors/partners/employees.) 0 to 2 years (a) 2 to 10 years (b) Over 10 years (c) General Building Contractor Trade Contractor Category 4M Trade Contractor Category 4MA Revised January 2007 3

Part 4 - Occupational Health, Safety and Welfare Compliance with the Occupational Health, Safety and Welfare (OHS&W) Act and Regulations is required. While supporting evidence of responses provided on this application form is not required at the time of submission, applicants should be aware that random checks of details provided on this application form will be conducted. A15 Does the contractor have an Occupational Health, Safety and Welfare policy and an Occupational Health Safety and Welfare Management System in place? Yes No A16 Does the contractor have a designated officer responsible for Occupational Health, Safety and Welfare? Yes No A17 and telephone number of the designated officer responsible for Occupational Health, Safety and Welfare. First (in full) Surname Telephone No. A18 Has the contractor received Workplace Services Improvement Notices, Prohibition Notices or had convictions recorded against it for the preceding 2 years from the date of this application? Yes No Part 5 - Industry Initiative The building and construction industry in South Australia has adopted the Code of Practice for the South Australian Building and Construction Industry as a Best Practice initiative. Copies of the Code of Practice are available from www.constructionsa.com.au or from DTEI by telephoning (08) 8226 5209. Prequalification assessment will consider how contractors have implemented the Code of Practice. While supporting evidence of responses provided on this application form is not required at the time of submission, applicants should be aware that random checks of details provided on this application form will be conducted. A19 Is the contractor aware of and working in accordance with the Code of Practice for the South Australian Building and Construction Industry and its objectives? Yes No Part 6 - Contractor All Risk Insurance - for Asbestos Removal Contractors only - all other applicants go to Part 7 A20 Does the contractor currently have Contractor All Risk (CAR) insurance? Yes No A21 What is the name of the insurance company? A22 What is the sum insured? $ A23 What is the amount of excess? $ A24 On what date does the current policy expire? / / Revised January 2007 4

Part 7 - Declaration I / We hereby make application for prequalification with the Department for Administrative and Information Services (DTEI) on behalf of the Government of South Australia as a prequalified General Building Contractor or Trade / Sub Contractor and declare that the particulars shown herein are true and correct in every detail. I / We also undertake to advise the Registrar of any changes to the circumstances of the contractor affecting the information contained in this application during the prequalification period. FIRST NAME (IN FULL) MIDDLE NAMES (INITIALS) SURNAME Position Signature Date / / Part 8 - Declaration as to Bankruptcy To the best of my knowledge, none of the proprietors, directors, trustees, managers or their spouses are or have ever been bankrupt or a director, manager or secretary of a company that is being or has been wound up (whether voluntarily or otherwise). none of the proprietors, directors, trustees, managers or their spouses are presently undeclared bankrupt. the business is not trading under:- an arrangement and / or restructuring receiver and manager official management an arrangement with creditors without sequestration. The contractor must provide, as an attachment, details of any of the proprietors, directors, trustees, managers or their spouses who:- have been or are bankrupt (if discharged state the date of discharge), or have entered into an agreement with any creditors without proceeding to bankruptcy, or have been a director, manager or secretary of a company which is being or has been wound up or is trading under an arrangement with creditors. Disclosure will not necessarily preclude an applicant from achieving registration. Position FIRST NAME (IN FULL) MIDDLE NAMES (INITIALS) SURNAME Signature Date / / Revised January 2007 5

Part 9 - Authorisations A25 Do you authorise DTEI to access Licence application information relating to the applicant from the Office of Consumer and Business Affairs? Yes... No... Signature Date / / A26 Do you authorise DTEI to access information and records relating to the applicant held by Workplace Services and Workcover Corporation Yes... No... Signature Date / / Revised January 2007 6

Part 10 Contractor Performance Separate Form Contractor Performance aims to measure the contractor s past experience in performing work appropriate to the category and type of work. For detailed requirements of performance reports and their use in the assessment process refer to the document Contractor Prequalification (Edition 2007) Building Construction Projects - Performance Assessment included in the Application Kit. Contractor Performance Reports will be used to ascertain the contractor's ability to qualify for registration as a general building contractor or specific trade contractor in the nominated category. Applicants will be required to demonstrate to the satisfaction of the Assessment Panel that they have the capacity to successfully and consistently undertake projects in each work/trade type. Applicants for registration as General Building Contractors or Trade Contractors in Categories 4M or 4MA are required to provide a minimum of one (1) performance report on a contract within the appropriate category value range and details of two (2) referees willing to provide verbal assessment of the Contractor s performance on two other contracts for General Building Contractor or for each trade group sought. Alternatively three (3) performance reports may be provided for each work/trade type. All contracts must have been completed within the preceding two (2) years prior to the date of application. The contractor s performance will be measured on each contract using a numerical rating and weighting scale (Refer to page 2 of the Contractor s Performance Reports). Weighting factors have been assigned to reflect the importance of individual requirements listed under each item. The weighting factor scale consists of a scale of 1 to 3, ordered from the highest (ie. 3) to lowest (ie. 1) in importance. For contractors applying for re-registration, all current performance reports on DTEI projects completed by the contractor will be taken into account in the assessment. If these project reports meet the value ranges and work/trades applicable to the prequalification sought in Part 2, no further reports need be provided. If however, additional reports are required to cover the work/trade and categories sought and/or the contractor wishes other contracts be taken into account, additional reports may be provided. Part 11 Financial Capacity Statement Applicants are required to provide with this application a statement from an independent accountant or banker, considered acceptable by the Assessment Panel, stating that the business has sufficient financial capacity to undertake projects up to the upper value of the applicable category range for the work type and specifically verify that the business has: (1) Sufficient liquid assets to meet project demands (Working Capital); sufficient financial capacity to undertake contracts up to the upper value of the applicable category range for the work type ($250,000 or $50,000) and it is in a position to meet its responsibilities to its creditors (including payment of subcontractors, suppliers, and employees). (2) History of profitable trading (Net Profit); there is profitability of the business, both declared and underlying. (3) Adequately capitalised (Net Worth and Shareholders Equity); the business has sufficient cash or access to cash by way of overdraft etc, capitalisation and net worth indicate sufficient cash flow to carry out contracts to the upper value of the applicable category range for the work type ($250,000 or $50,000), the degree of risk or security introduced by non-contracting business activity is manageable, and there is access if required, to guarantee facilities through assets held outside the business. The statement shall be signed by an authorised representative of the accountant or banker and contact details of the person and organisation making the statement provided. Revised January 2007 7

DIRECTIONS TO APPLICANTS. Check that all of the following parts of the application have been fully completed and included prior to submission: Application form Performance reports and/or details of referees and projects Financial Statement To be accepted for inclusion on the prequalification register for contractors, an applicant must meet the minimum benchmarks for all of the criteria. A fee of $170 payable to the Department for Transport, Energy and Infrastructure (DTEI) must accompany the completed application form. Applications for prequalification will not be assessed unless accompanied by the full fee payable. The completed application forms should be forwarded to the Prequalification Registrar, Building Management, DTEI, GPO Box 967, Adelaide SA 5001 or Level 2, 211 Victoria Square, Adelaide SA 5000, between the hours of 9 a.m. and 4 p.m. Contractors seeking prequalification and submitting completed application forms will be notified if successfully prequalified by way of a certificate. Any enquiries should be directed to the Registrar, on telephone (08) 8226 5209 or facsimile (08) 8226 5588. Revised January 2007