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Membership & Payment (Annual)

* Indicates required field

Check one *

Bronze ($2,500) Silver ($5,000) Gold ($7,500) Platinum ($10,000) Titanium ($15,000) Infrastructure Partner ($25,000)

Cash / Check Payment: Cash or check payment is accepted. If by check, make payable to: UNITED HISPANIC CONTRACTORS

Company Information

Company name *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Are you a member of Better Business Bureau (BBB)? *

Yes No

Describe your business or service in detail *

Offers services: *

Residential Comercial Industrial Other

What other service *

Maximum project or job you can handle (in dollars): *

Owner Information / Licenses / Insurance / Security

Company Representant *

#Tel *

Email *

Coordinador de seguridad *

#Tel *

Email *

Is your business registered with the state? *

Yes No

Which state? *

Starting date *

Legal type of company? *

EIN# (Federal Business Tax #) *

How many employees do you have (full time)? *

How many employees do you have (part time)? *

Do you use subcontractors? *

Yes No

Do you have a state contractor's license? *

Yes No

Do you have a city contractor's license? *

Yes No

Do you have other licenses? *

Yes No

Specify which licenses or permits you have *

Category / Type of service offered (3 maximum categories) (Example: Framing, Concrete, Painting, Roofing, etc.) *

Insurance

Do you have General Liability Insurance? *

Yes No

Maximum coverage $ *

Do you have Workers' Compensation Insurance? *

Yes No

How many employees do you have? *

Do you have Bond Insurance? *

Yes No

What is your bonding limit? $ *

Seguridad (Safety)

Do you have OSHA 10? *

Yes No

Do you have OSHA 30? *

Yes No

Do you perform project safety inspections? *

Yes No

Do you have a drug testing program? *

Yes No

Does your company have a written safety program? *

Yes No

Do you have an orientation program for New hires? *

Yes No

Supervisors or Sub-Contractors? *

Yes No

How often do you hold safety meetings? *

The following information is for statistical purposes only (optional)

Do you consider your company as a small business? *

Yes No

Owner is: *

Male Female

Owner is: *

White Afro-American Hispanic/Latino American Indian/Native Asian

Owner is: *

Veteran Veteran Disabled

The business is: *

Part of a union NOT part of a union

Type of business *

General Contractor Sub-Contractor Manufacturer Material supplier Consultant Service Provider Other

Type of business *

I agree to be a member of the United Hispanic Contractors Association and agree to all terms/rules of said organization: *

Yes

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Office:
4104 S 42nd St., Omaha, NE 68107

Phone:
(531) 333-4646

Email:
info@unitedhispaniccontractors.com

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