17vendor Pre-Qualification Form
17vendor Pre-Qualification Form
17vendor Pre-Qualification Form
Company/Contractor Name:
______________________________________________________
Province(s) of Operation:
________________________________________________________
Type of services being considered for:
______________________________________________
______________________________________________________________________
Name (print) Signature Date
Number of Fatalities
Number of Lost Time Injuries
Name:
Title:
Phone:
Fax:
Email:
Do you have a written Health, Safety, and Environmental (HSE) Yes No N/A
Policy? If yes please attach a copy.
Does your company have a Certificate of Recognition (COR)? If Yes No N/A
yes please provide a copy. If no see instructions below (page 4)
Does your company have HSE supervisors and/or coordinators? Yes No N/A
If yes please provide names, contact numbers, and training
details.
Does your company have a documented HSE Management Yes No N/A
System in place? If yes please provide a copy of the Table of
Contents.
Has your company had an HSE audit conducted in the past three Yes No N/A
Vendor Management – Vendor Pre-qualification Form
Environmental Considerations
Please provide any other information with regard to your company Health, Safety, and
Environmental Management program that you feel would be relevant to this evaluation or
the above questions. Attach separate page if needed.
Vendor Management – Vendor Pre-qualification Form
The following section is to be completed only if the potential contractor does not have a
valid and sustaining Certificate of Recognition (COR)
Do you evaluate your safety program to ensure it is effective and Yes No N/A
that all areas for improvement are identified? How often? Provide
details:
Feedback and/or additional information provided by the contractor on above list of items:
Vendor Management – Vendor Pre-qualification Form
References
List the names of recent client organizations that you have worked for and who may be
contacted for references for projects completed and/or work in progress for the intended
crew:
Reviewed by:
Date:
Comments:
If yes, please complete the section below identifying actions required. Must be signed by
Vendor Senior Management
Vendor Name:
Date:
4.
5.
6.
The above mentioned vendor has agreed to implement continuous improvement activities
described above within the designated time frames as a condition of hire. The vendor
agrees to a company representative completing a follow-up review of action plan within
one year of signing and acknowledges that failure to satisfactorily implement this action
plan may result in the vendor being removed from the company Pre Approved Vendor
List.
Company Representative: