M. C. Dean, Inc Vendor and Subcontractor Survey
All prospective subcontractors/suppliers interested in working on M. C. Dean, Inc., projects are
required to complete this questionnaire. The contents of this questionnaire will be considered
confidential and used solely to determine your firm’s qualifications and will not be disclosed to
others. If your procedures require, M.C. Dean will sign a non-disclosure agreement with your
company. Please direct any questions and return the completed form to:
SmallBusiness@mcdean.com . PLEASE WRITE CLEARLY!
Company Contact Information
Business Name:
Contact Person and Title:
Address:
Telephone number:
Fax number: _________________________
Email:
Website Address:
Up to what size single project do you want to be prequalified for? $
M. C. Dean, Inc. is an Equal Employment Opportunity and Affirmative Action Employer. Applicants are
considered for all positions and are treated during employment without regard to race, religion, sex,
national origin, age, disability, marital or veteran status, genetic information or any other basis prohibited
by law. As a government contractor, we comply with government regulations and affirmative action
responsibilities.
Business Information
Year Established:
State of Incorporation:
Number of Employees:
DUNS Number:
CAGE Code: _____________
NAICS Codes (Top 3 by Revenue):
Federal Tax ID Number:
Business type:
_____________
Corporation
Partnership
Sole Proprietor
Limited Liability Company
Other (specify) _________________________________
Ownership (constituting more than 5%)
Name
Age
% Ownership
Position/Duties
Years Exp in
This Business
Are owners active in daily business? _____ How many years in business under present ownership:
What trades of work do you usually perform with your own forces?
What percent (%) of work is done by your own workforce? ____________
Total number of permanent staff presently employed by firm:
The above-referenced permanent staff employment includes the following # of people:
Management
#
Superintendents
#
Engineers/Arch.
#
Foremen
#
Draftsmen
#
Skilled Craftsmen #
Project Managers
#
Unskilled Labor
#
Project Engineers #
Other
#
Estimators
#
Other
#
Licensing Information
Please provide a copy of all trade and professional licenses.
Type of license/name of licensee
State
License number
_______________________________
_______________________________
_______________________________
_______________________________
_____
_____
_____
_____
_______________
_______________
_______________
_______________
Has any license ever been denied or revoked?
separate sheet.
No
Yes if yes, please describe on a
Indicate if your business qualifies as one of the following: (check all that apply):
DBE(Disadvantaged Business Enterprise)
MBE(Minority Business Enterprise)
SBE(Small Business Enterprise)
WBE(Woman owned Business Enterprise)
Other (specify)___________________
SWAM
VET OWNED
8(a)
SBSDVO
HUBZONE (Empowerment Contracting Program)
Any special certifications awarded etc. (MWAA, VDOT, MDOT) ________________
Safety Information
YEAR 
Workers’ Compensation Experience Modification
Rate for last three years.
NOTE: If EMR Average for last three years is over 1.0, you must submit an OSHA 200 log for each year with this
response.
Have you had any OSHA fines within the last three years?
Have you had any jobsite fatalities within the last three years?
YES 
YES 
NO 
NO 
If you have answered YES to either of the above two questions, you MUST submit on separate
sheet the details describing the circumstances surrounding each incident.
Financial Information
Please submit last two years financial statements for your company. The financial statements
should be the year-end CPA prepared statements with all attachments including a WIP (Work in
Progress Report). A current internal statement should be provided as well if it has been 6 months
or more since the last fiscal year-end.
Please indicate this year’s estimated annual sales volume. $ __________
**Please fill out both Project sheets: Present Projects, Projects completed within the Past
Three Years. ** (attached)
BONDING:
Surety Company:
Agent Company:
Agent Contact:
Phone: (
)
Your Bonding Capacity: Single $
Aggregate $
Largest Bond Issued $_______ Most Recent Bond Amount $______ Date of Bond ___________
**Please attach a letter from your bonding company, signed by an attorney, verifying the Surety name, length of
relationship and single and aggregate limits reflected above.
INSURANCE:
Insurance Company:
Agent Company:
Agent Contact:
Has your surety ever finished one of your projects?
complete explanation on a separate sheet.
Phone: (
No
)
Yes if yes, please provide a
COVERAGE TYPE LIMITS
Workmen’s Compensation: __________________________
General Liability: __________________________________
Excess / Umbrella Liability: __________________________
Automobile Liability: ________________________________
Please attach a certificate of insurance describing coverage limits.
Operations Information
Current Areas of Operation (please check all that apply):
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Alabama
Colorado
Hawaii
Kansas
Massachusetts
Montana
New Mexico
Oklahoma
South Dakota
Virginia
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Alaska
Connecticut
Idaho
Kentucky
Michigan
Nebraska
New York
Oregon
Tennessee
Washington
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Arizona
Delaware
Illinois
Louisiana
Minnesota
Nevada
North Carolina
Pennsylvania
Texas
West Virginia
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Arkansas
Florida
Indiana
Maine
Mississippi
New Hampshire
North Dakota
Rhode Island
Utah
Wisconsin
 California
 Georgia
 Iowa
 Maryland
 Missouri
 New Jersey
 Ohio
 South Carolina
 Vermont
 Wyoming
Please identify the services you provide:
Acoustical Tile
Appraisals
Architect/Engineering
Asbestos Removal
Bird Proofing
Boiler Repair & Installation
Carpentry
Cassions
Cathodic Protection
CCTV Systems
Concrete Work
Construction Inspections
Construction Management
Construction Testing
Cooling Towers
Core Drilling
Demolition
Direction Boring
Doors/Windows
Electrical
Elevator Installation
Elevator Seismic Protection
Environmental Work
Exterior Building Cleaning
Fencing
Fire Protection Systems
Fireproofing
Floors
Fuel Tank Removal
Furnishings Installation
Hydro seeding
Information Display Systems
Instrumentation
Insulation Pipes
Landscaping
Lead Abatement
Lighting Protections
Masonry Work
Metals
Neon Signs
Painting
Partition Installation
Paving
PCB Removal
Phone Services
Plumbing
Railroad Extensions
Railways Bit, Concrete
Refrigeration Work
RFI Shielding
Rigging & Hauling
Roofing
Safety
SCADA Systems
Security Systems
Shoring
Software
Solar Energy Systems
Solar Film Projects
Space Planning
Special Systems
Tank Installation
Tank Lining Installation
Test Boring
Waterproofing
Welding
Woodwork
X-Ray Testing
Other _____________
Other _____________
Other _____________
Other _____________
Please mail this form along with copies of any small business certifications (e.g. Woman-Owned,
Small Disadvantaged, HUBZone, etc.) fax the completed form to: Small Business at (703) 437-1114.
Reference Information
Please provide THREE OWNERS, GENERAL CONTRACTORS, OR CONSTRUCTION
MANAGERS YOU HAVE WORKED FOR WITHIN THE PAST TWO YEARS and any
additional information you feel will help us determine your firm’s qualifications and
expertise.
Reference # 1:_________________________________ Contact: __________________________
Address: _____________________________________ State: _______ Zip Code: ____________
Telephone: ___________________________________ Fax: _____________________________
Reference # 2:_________________________________ Contact: __________________________
Address: _____________________________________ State: _______ Zip Code: ____________
Telephone: ___________________________________ Fax: _____________________________
Reference # 3:_________________________________ Contact: __________________________
Address: _____________________________________ State: _______ Zip Code: ____________
Telephone: ___________________________________ Fax: _____________________________
LIST TWO TRADE REFERENCES (or attach a list of trade references with this response)
Reference # 1:_________________________________ Contact: __________________________
Address: _____________________________________ State: _______ Zip Code: ____________
Telephone: ___________________________________ Fax: _____________________________
Reference # 2:_________________________________ Contact: __________________________
Address: _____________________________________ State: _______ Zip Code: ____________
Telephone: ___________________________________ Fax: _____________________________
Has firm:
- Failed to complete a contract
YES 
NO 
- Been involved in bankruptcy or reorganization
YES 
NO 
- Pending judgment claims or suits against firm
YES 
NO 
(If answer to above is yes, submit details on separate sheet.)
I hereby certify that all information provided is accurate, correct and true.
Completed by:
Name (Please print clearly)
Title
Signatur
SUPPLIER BUSINESS CLASSIFICATION
Supplier Code: __________________________________________________________________________________
Company Name: ________________________________________________________________________________
Address: ______________________________________ City: ___________________ State: ______ Zip: __________
Contact Person: _______________________________ Email: ____________________________________________
Phone: _________________________ Fax: ____________________ Website (optional) _______________________
Type of Business: ___________________________ Number of Employees: ________ DUNS #: __________________
Major Product Lines: _____________________________________________________________________________
NAICS Code(s): __________________________________________________________________________________
CERTIFICATION
Please check all business classifications applicable to your company, the Supplier:
□ Large Business concern – a business that exceeds the small business size code standards established by the
U.S. Small Business Administration as set forth in code of Federal Regulation 13 CFR Part 121.
□ Alaska Native Corporations (ANCs) and Indian Tribes that are not small businesses.
□ Alaska Native Corporations (ANCs) and Indian Tribes that have not been certified by the Small Business
Administration as Small Disadvantaged Businesses.
□ Small Business Concern – a business, qualified as a small business under the criteria in 13 CFR Part 121.
□ Small Disadvantaged Business Concern – a small business is at least 51 percent owned by one or more
individuals who are both socially and economically disadvantaged and control the management and daily
business operations. (As of October 1, 2008 the Small Business Association no longer requires formal
certification.) Please check the group your business qualifies for below:
 African American
 Hispanic American
 Asian Pacific American
 Subcontinent Asian American
 Native American (American Indian, Eskimo, and Aleut)
 Other, Please Specify ____________________________________________________________
□ Women-Owned Business Zone Concern – a small business owned, controlled and managed by one or more
woman as defined in FAR 52.219-8 and 48 CFR 2.101.
□ Historically Underutilized Business Zone Concern – a small business that appears on the list of Qualified
HUBZone Small Business Concerns maintained by the Small Business Administration pursuant to 13 CFR Part
126.
Supplier must forward a copy of its HUBZone Certification from the SBA along with this form; if you have not
received certification from the SBA, please consult the SBA’s website for the certification process and forward
a copy upon completion.
□ Service-Disabled Veteran-Owned Small Business Concern – a small business that is owned, controlled and
managed by one or more service-disabled veterans (as defined in 38 U.S.C. 101(2), with a disability that is
service-connected, as defined in 38 U.S.C. 101(16)) (or, in the case of a service-disabled veteran with
permanent and severe disability, the spouse or permanent caregiver of such veteran) as defined in FAR
52.219-8 and 48 CFR 2.101.
□ Veteran-Owned Small Business Concern – a small business that is at least 51 percent by one or more
veterans (as defined at 38 U.S.C. 101(2)) who control its management and daily business operations as
defined in FAR 52.219-8 and 48 CFR 2.101.
□ Historically Black Colleges and Universities (HBCU) and Minority Institutions (MI).
□ SBA 8(a) Certified.
□ Other , Please Specify __________________________________________________________________
Under 15 U.S.C. 645(d), any person who misrepresents a firm’s status as a “small business” in order to obtain a
contract to awarded under the preference programs established pursuant section 8(a), 8(d), 9, or 15 of the Small
Business Act, or any other provision of the Federal law that specifically references section 8(d) for a definition of
program eligibility, shall be punished by imposition of fine, imprisonment, or both; subject to administrative
remedies, including suspension and debarment; and, ineligible for participation in programs conducted under the
authority of the Act.
□ Labor Surplus Area – Company is located in a geographical area identified by the Department of Labor in
accordance with 20 CFR Part 654, Subpart A, as an area of concentrated unemployment or
underemployment, or an area of labor surplus. See FAR 19.001.
□ Non-Labor Surplus Area – Company is not located in a Labor Surplus Area.
Signature of Certifying Official: __________________________________________________________________
Printed Name: _________________________________________________________ Date: _________________
Please return completed forms to:
If submitting via email, please scan a signed copy of
the form into PDF file or other image file, or complete
in Adobe Acrobat and sign using digital signature tool.
Contracts Service Center
M.C. Dean, Inc.
22630 Davis Drive, Suite 100
Sterling, VA 20164-4000
Fax: (703) 437-1114
Email: small.business@mcdean.com
FOR OFFICE USE ONLY
□ Updated AS400
□ Updated Contracts Online
Date: _______________ Print Name: ________________________________
Date: _______________ Print Name: ________________________________
COMPLETED PROJECTS WITHIN THE PAST THREE YEARS
PROJECT NAME
OWNER
ARCHITECT
CONTRACT AMOUNT
DATE OF
COMPLETION
PERCENTAGE OF COST
w/OWN WORK FORCE
PRESENT PROJECTS
PROJECT NAME
PROJECT
MANAGER
CONTRACT
AMOUNT
EST. DATE OF
COMPLETION
COMMENTS