Current Date:
Did someone at SRG request you to complete this form? If so, name:
Do you require SRG to complete your Company credit application? YesNo
(if “yes”, attach your credit application for SRG’s execution. Please be advised that no T&C’s will be entertained by SRG in the credit application, payment or other terms shall be subject to each individual Purchase or Subcontract Order).
Have you worked for SRG in the past year? YesNo
Are you deemed by CRA to be a ‘Subcontractor’ pursuant to line 295 of the T5018? YesNo
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Thank you for your interest in becoming a Site Resource Group Inc., Bears Access and Environmental Inc., Site Equipment Ltd., and/or Force Copps Piling Inc. (together “SRG”), 3rd Party Supplier. At SRG, our due diligence requirements set out by our Contracts Center of Excellence (“CCOE”), mandates that we evaluate all 3rd Parties engaged in our supply chain. In efforts to fulfill our commitment, we must understand the processes, culture and business acumen of our 3rd Parties. Once prequalified, SRG will require updated questionnaire information annually, and updated insurance information as the current coverage expires. All submissions shall remain “for internal use only” at SRG, and will not be provided to external sources. The prequalification process does not preclude requests for additional information as designated by projects and/or specific work sites. We appreciate the time and effort you’ve taken in providing accurate information to SRG. Please note that completion of this questionnaire, including gathering documentation and/or related communications does not constitute work for SRG, and therefore this task is not billable.
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Please note the completion of this questionnaire is MANDATORY regardless of supply type. However, based on supply type, some Sections may not be applicable to every 3rd Party Supplier, resultantly please read the instructions in each section carefully. Once complete, please email this completed form along with the required verification documents to: Vendors@siterg.com
All required questions must be answered and details provided as requested. Incomplete responses or missing information may result in delay of the approval process, or in rejection of your submittal.
If a subsection or specific question is not applicable to your business, please mark as “N/A”. Where “N/A” is set out as your response, you may be contacted by an SRG representative, for further clarification.
Do you perform any of the following Critical tasks? (Check any and all that apply). If none apply, please leave blank, if they apply the title “Subcontractor” shall be assigned to your firm:
Confined Space EntryLifting Operations or Material HandlingWater or Ice Working EnvironmentsMobile/Heavy Equipment OperationsHazardous Materials & Environments*Project or Construction oversightAerial or Marine WorkFabrication or ManufacturingHot WorkWorking at HeightsTraffic Conditions, Traffic Controls & TransportDrilling OperationsSecurity or FirearmsHazardous Energy (including Lockout/Tag out and/or Electrical)Use of Regulated Equipment e.g. nuclear gaugesNoxious flora/aggressive fauna controlsEngineering or Design ServicesActivities on a construction site that require your personnel in attendanceAgent, Broker, or ConsultantGround Disturbance to any level (includes Utility Locates and Excavation as examples) *e.g. asbestos, unoccupied buildings, construction, hazardous waste, live energy, active traffic zones, etc. [cf7mls_step cf7mls_step-3 "Back" "Next" "Step 3"]
SERVICES, EQUIPMENT &/OR PRODUCT TYPICALLY PROVIDED TO SRG:
Please check off all the commodities that apply to your company in this table.
Subcontractor (Safety Sensitive) Sections 1-8 & 10 apply. *Exemptions to Section 9 (QAQC) may be granted for those italicized commodities.
ON SITE WORKS
*Aerial Works;Architectural;enterBuildings;Civil Works;Cleaning – Industrial (Chemical/Steam);Coatings;*Communications;Concrete (precast/structural);Concrete (pre-stress/post tension);Cranes, Monorail, Bridge, Polar;Construction Services;*Consulting;*De-Watering;Doors, Industrial, Fire;Drilling;Ductwork, Conventional Sheet Metal;Ductwork, Heavy Gauge Metal;Electrical Construction – General Contractor;Electrical Construction – Outside (pole line);Electrical Construction – Transmission;*Environmental Services;*Fencing;Fire Protection;Flow-lines;Foundations, Equipment Setting;Geomatics;Heat Treatment/Stress Relieve (on site);Heating, Ventilation, Air Conditioning (HVAC);Heavy Haul/Lift, Rigging;Hydro-testing;*Hydro-Vac;Instrument and Controls, DCS;Inspection/Testing;Insulation – Materials, Thermal, Wallboard;Insulation – spray on;Insulation – Thermal, Conventional;*Janitorial;*Labour Broker;Marine;Mechanical;Mechanical Fabrication;Module Erection;*Module Accommodation or Camp;Maintenance;Manpower & Resources;Piling;Piping;Piping Fabrication;Pipeline;Pressure Vessels;Protective Service;Service Work;Siding – Fibreglass;Siding – Metal;Specialty Services (describe below);Startup Assistance, Testing, Training;Steel Fabrication;Structural;Surfacing Membranes for Roads, Tank Farms;Survey, Aerial Mapping and Photography;Tankage, Bins, Fiberglass - Plastic;Tankage, Bins, Silos – Concrete;Tankage, Bins, Silos – Metal;Tankage, Pads and Dykes;*Temporary Facilities (temp. power, propane, potable-water, septic services);Testing, Chemical Analysis;Testing, Nondestructive Examination for Piping;Transport (Gravel Only);Transportation;Underground Utilities;Walls, Curtain, Glass, Aluminum;Welding
Vendor Type A (Quality Sensitive) Sections 1-9 & 10 apply. *Exemptions to Section 8 (HSSE) apply.
OFF SITE WORKS
*Crushing/Screening (process plant);*Design or Engineering;*Electrical Switchyards;*Steel Supply;*Testing, Soil, Concrete – Destructive
Vendor Type B (All Others) Sections 8 & 9 (HSSE & QAQC) are exempt for all commodities in this section.
OFF SITE WORKS and NON-QUALITY SENSITIVE SUPPLY
Air Travel;Banks/Financial Institutions;Consumables;Department Stores;☐Drug (safety) Testing;Equipment Rental;Equip. Parts or Maintenance;☐Fuels/Lubricants;Government Firms;Gravel Supply;Hotels;Insurers;Landlords;Law Firms;Office Supplies;Restaurants;Safety Supplies;Signs;Small Tools;Software;Tax Authorities;Training (off site);Utility Providers
(IF COMMODITY IS NOT LISTED ABOVE)
Describe:
GENERAL COMPANY INFORMATION
Company’s Legal Name: (list all companies applicable)
Jurisdiction of Registration:
Company #:
Registration (Tax ID #):
Registration Date:
Registration Expiry Date:
Date Established:
GST No.:
Alternate Trade or Business Name (doing business as):
Are You a Publicly Traded Company? YESNo
Stock Exchange:
Ticker Symbol or equivalent:
Please indicate which of these best describes your business: Individual/Sole ProprietorshipPartnershipCooperativePublically Traded CorporationPrivate CorporationLimited Liability PartnershipPublicly Owned CompanyOther
If “Other”, please specify:
Please indicate which of these best describes your business structure: Simple Company StructureCanadian SubsidiariesOverseas SubsidiariesJoint VentureConsortia
Please indicate which of these best describes where your business operates?
Single site in CanadaMultiple sites in CanadaWorking in USAGlobal
Mailing Address:
City/Town & Province:
Postal Code:
Phone:
Website:
How many years has your organization been in business?
Is your business required to be registered with any governmental or other organization in order to provide services? YESNO
If “yes” please list:
Does your Company participate in Indigenous cultural awareness training programs? YESNO
Please indicate if applicable: First Nation,Metis,Inuit,Other Minority Group,N/A
If “Other Minority Group”, explain:
What % of Indigenous ownership, if any, does your Company have:
Name:
Email:
EFT remittance email address:
List of goods/services/equipment normally provided by your company, that you may contract to others: [cf7mls_step cf7mls_step-4 "Back" "Next" "Step 4"]
Insurance and Worker’s Compensation are required as part of SRG’s prequalification process.
WORKERS’ COMPENSATION INFORMATION
Does your company have Worker’s Compensation Coverage? YESNO
WCB Account Number (Code & Classification) – BC:
WCB Account Number (Code & Classification) – AB:
WCB Account Number (Code & Classification) – SK:
WCB Account Number (Code & Classification) – MB:
Other:
British Columbia
WCB rates for the previous 3 calendar years:
Industry Base Rate
Your Company’s Experience Rate
% Discount or Surcharge
Is your Account in Good Standing? YESNO
Alberta
Saskatchewan
Manitoba
Attach the following: Provincial WCB - Employer Premium Rate Statements; and Provincial WCB - Letter of Good Standing. (attach for each jurisdiction applicable to your company) Please note three (3) years’ worth of rate letters will be assessed and must include current year – ensure this is adhered to when submitting your documents.
GENERAL BUSINESS INSURANCE
Name of Insurance Broker: Contact Name: Telephone:
For specifics on coverage – See EXHIBIT A (Insurance Requirements). Please ensure you attach a copy of your current COI. It must name “Site Resource Group Inc., Bear Access & Environmental Inc., Force Copps Piling Inc. @ 170, 120 Pembina Rd., Sherwood Park, Alberta, T8H-OM2” as an additional insured.
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Please answer all questions to the best of your knowledge.
COMPANY
Does your company have a Compliance Officer (or equivalent)? YESNO
Does your company provide compliance and anti-corruption training to employees? YESNO
Does your company have a Code of Conduct or specific anti-corruption policies in place? If “yes”, please include a copy. YESNO
Does your company agree to comply with the SRG Code of Business Conduct Policy and the SRG Anti-Bribery & Corruption Policy? YESNO
During the past five (5) years have you, your company or any Board of Directors, Key Officers, Key Employees or Beneficial Owners (as applicable), been the subject of any actions resulting from suspension, debarment, or disqualification? YESNOc
* Have you, your company or any Board of Directors, Key Officers, Key Employees or Beneficial Owners (as applicable) ever been charged or convicted of any financial crime, fraud, or corruption-related offense? YESNO
SERVICES
During prospective work with SRG or the services offered, do you/your company anticipate any interaction with government employees? (including, but not limited to, interaction with licensing agencies, customs officers, and local tax authorities) YESNO
* Are you or any of your Board of Directors, Key Officers, Key Employees or Beneficial Owners currently, or have they been in the last year, a government employee pursuant to the services you will be providing to SRG, or do they currently have close family ties with a government employee involved with the services to be provided? YESNO
* Have you/your company, or any Board of Directors, Key Officers, Key Employees or Beneficial Owners (as applicable) been or currently employed by a separate entity affiliated with another party to any transaction relating to the services? YESNO
* Have you/your company or any affiliates or partner firms or individuals paid or are they going to pay any governmental official any compensation or fee in connection with the awarding or oversight of any services to be provided or anticipated? YESNO
* Do you/your company intend to pay, directly or indirectly, any commission or finder’s fee to a third party or agent relating to the services? YESNO
If no, what is your position on this?
HUMAN RIGHTS, TRAFFICKING, AND MODERN SLAVERY
Does your company protect human rights? YESNO
Does your company prohibit human trafficking and modern slavery? YESNO
Social Accountability Certification
Are you certified for Social Fingerprint (click for more information) YESNO
If yes, please provide a copy of your current certification, including a summary of any recent audits to ensure compliance with the SA8000 standard.
COMPLIANCE CERTIFICATION
On behalf of company, I attest and certify, in connection with our engagement to provide goods, equipment or services to Site Resource Group Inc., its subsidiaries and its affiliates (“SRG”), that I have received a copy of the SRG Business Ethics & Conduct Policy and its Anti-Bribery & Corruption Policy (“SRG Policies”), and I have read and understood its provisions, and am authorized to sign this certification individually and on behalf of the Company. Resultantly, I hereby covenant and agree that all Company persons (including lower tier subcontractors) providing by company to SRG, shall: (i) be advised of the SRG Policies; (ii) such parties shall comply with SRG Policies in addition to any such applicable laws in the jurisdiction; (iii) affirm that no commissions, or any other money or thing of nominal value has been or will be paid, offered, given promised or authorized directly or indirectly by Company to any Government Official and/or target Customer for the purpose of influencing any act, inaction or decision of such person, securing an improper advantage from such person, or inducing any such person to use their influence with Government and/or target Customer to affect or influence any such act or decision of such Government or target Customer; (iv) will keep complete and accurate records that fairly reflect the transactions and expenses related to the Company business and the records shall state in reasonable detail the purpose of each expense and the receipt and distribution of the asset; and finally (v) Company agrees that if future developments cause the representations and certifications provided herein to no longer be accurate or complete, it will promptly send SRG a written report detailing the causes and extent of the changes.
I AGREEI do NOT Agree [cf7mls_step cf7mls_step-6 "Back" "Next" "Step 6"]
Please be advised that prior to first payment, your Finance Representative set out in Section 4, shall receive a phone call to verify banking details from a SRG Finance Representative.
General Info:
Does your Company have audited financial statements? YESNO
If yes, and you have done more than $2M in work with SRG in the past calendar year, please provide copies for the last 3 financial years.
$ Value last calendar year:
Company’s books and records maintained in accordance with your country’s standards or internationally accepted accounting standards? YESNO
Financial Volumes: Annual billings for the last three years
2020
2019
2018
Equity / LOC Available:
Banking Information – CANADIAN
NOTE: Please provide a void cheque or bank issued document, endorsed by your bank.
Bank Name:
Bank Address:
Bank Phone Number:
Transit No.: (5 Digits)
Account No.:
Bank ID No.:(3 Digits)
# of Yrs with Bank:
IF APPLICABLE – International Wire Payments
NOTE 1: Please provide additional intermediary bank details, if used by beneficiary (vendor) for international payments. If banking information differs for payment in non-CAD currency, please provide details. NOTE 2: Please provide a void cheque or bank issued document endorsed by your bank.
Beneficiary (vendor) name and address:
Beneficiary Bank Name:
Beneficiary Bank Address:
Swift Code / BIC:
IBAN:
If necessary, please provide other bank references on a separate sheet.
*Company hereby authorize and direct that all payments due to the Company from SRG shall be directly deposited into the above named bank account. We agree that SRG will not be liable for any loss occurring after the deposit has been made to the identified bank account. We also agree that any duplicate payment, overpayment, fraudulent payment made in error will be promptly returned to SRG. We acknowledge and agree that it is our responsibility to provide correct information.
Securities
Name of Surety Company:
Bonding Agent:
Contact Name:
Telephone:
Available Bonding Limits
Performance & Labour Bond: Maximum
Material Payment Bond: Maximum
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OWNERSHIP
List all Owners (Companies or Individuals) of Company.
Ownership percentages must total 100%
Please provide the names of each legal and beneficial shareholder, together with a list of any majority or controlling interest in any other Company. If publically traded list each shareholder holding 5% or more individually.
Also, list all companies owned or controlled by Company.
Please provide a detailed list of any subsidiaries or parent company including registered number, country of registration and % of subsidiary owned.
Where possible please also provide the details in the form of a group structure chart.
Do you have ownership/affiliates? YESNO Please List:
BOARD OF DIRECTORS
Please list all Members of the Board of Directors and all Officers of your company.
KEY EMPLOYEES
“Key Employees”: anyone with managerial responsibility (e.g. Director, CEO, or CFO) and any other employee with decision-making authority relevant to site products or services or involved with projects involving site products or services;
EXPORT CONTROLS
Does your company have an export control and sanctions program? YESNO
Does your company check designated persons lists for entities with whom the contract or supply (i.e. the end or actual users)? YESNO
What other diligence and background checks are carried out by your company prior to entering into contracts? Please provide details below.
Please provide details below of all freight forwarders used by your business.
REFERENCES
Please provide a list of three (3) recent project references as set out below:
Has your company ever failed to complete a contract awarded to you? YESNO
Has your company ever evoked its lien rights? YESNO If yes, please explain:
LEGAL ACTIONS
Are there any judgements, claims or suits pending or outstanding against your company? YESNO If “yes”, please provide details:
Are you now, or have you ever been involved in any bankruptcy or reorganization proceedings? YESNO If “yes”, please provide details:
LABOUR RELATIONS
Number of permanent employees: Please describe any affiliations with labour organizations:
Please list all trade agreements or labour contracts that your company or any affiliate is a signatory to (include expiry dates):
*Please submit a copy of your Annual RATE schedule, if applicable ☐attached ☐not attached
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SAFE WORK PERFORMANCE
Injury Experience / Historical Performance for the Company
Use the current and previous 3 years injury and illness records to complete the following:
# of Medical Treatment Cases:
# of Restricted Work Day Cases:
# of Lost Time Injury Cases:
# of fatal injuries:
Total Recordable Injury Frequency:
Lost Time Injury Frequency:
# of man-hours:
Definitions:
“Medical Treatment Cases” any occupational injury or illness requiring treatment provided by a physician or treatment provided under the direction of a physician. “Restricted Work Day Cases” any occupational injury or illness that prevents a worker from performing any of his/her craft jurisdictional duties. “Lost Time Injury Cases” any occupational injury that prevents the worker from performing any work for at least one day. “Total Recordable Injury Frequency” is the total number of Medical Treatments, Restricted Work Day Cases and Lost Time Injury Cases multiplied by 200,000 divided by total man-hours. “Lost Time Injury Frequency” is the total of Lost Time Injury Cases multiplied by 200,000 then divided by total man-hours.
*PLEASE PROVIDE A DESCRIPTION OF ANY LOST TIME INJURIES OR FATALITIES IDENTIFIED ABOVE.
Do you have a full-time dedicated Safety representative? YESNO
Has your HSSE Management System been evaluated using an industry recognized audit within the last three (3) years? Examples include: COR/SECOR, OHSAS 18001, ISO 14001, ISRS. (if yes, please provide copy of certificate and most recent audit summary) YESNO
H&S Inspections and Audits Explain your company’s process for investigations; including any root cause analysis techniques
How are incidents reviewed to prevent future occurrence?
ORDERS AND CITATIONS
Has your company been cited, charged or prosecuted under the Alberta Occupational Health and Safety Act or the Alberta Environmental Enhancement and Protection Action (or such other legislation applicable in the jurisdictions worked), in the previous 3 years? YESNO
Has your company ever been barred from working on any site, or been required to stop work due to an HSSE violation? YESNO
If “yes”, provide details:
In the past three (3) years, has an OH&S or Environmental Regulator ever had cause to investigate your worksite? (not including regular inspections)? YESNO
In the past three (3) years, has an OH&S or Environmental Regulator issued orders or citations against your company for HSSE violations? YESNO
SAFETY PROGRAM
Do your company have a written safety program manual? If “yes”, provide an electronic copy. YESNO
Does your safety program contain the following elements:
Core Policies YESNO
Rules & Regulations YESNO
Awards & Recognition YESNO
Safety Inspection & Audits YESNO
Training & Competency YESNO
Meetings & Communications YESNO
Journey Management YESNO
Claims Management YESNO
Occupational Health YESNO
Security YESNO
Environmental Management YESNO
Roles & Responsibilities YESNO
Preventative Maintenance YESNO
Hazard Assessment YESNO
Subcontractor Controls YESNO
TDG/WHIMS YESNO
Records, Stats & Document Control YESNO
Incident Reporting & Investigation YESNO
Drug & Alcohol Program YESNO
Emergency Response YESNO
Office Safety YESNO
Bullying / Harassment YESNO
HSSE TRAINING
Can your company demonstrate that your employees have the required competencies for specific functions or high-risk tasks? If “yes”, please provide a copy of the procedure used. YESNO
Understanding of training is verified by: Written Test;Oral Test;Performance Test;Performance Test;Mentoring;Other
If ‘other’ please specify:
ORIENTATION & TRAINING PROGRAMS
HSSE Orientation Program Do you have a HSE Orientation Program for new hires as well as newly hired or promoted supervisors?
New Hires YESNO
Supervisors YESNO
Does the ORIENATION Program include the following:
General Rules & Regulations YESNO
Emergency Reporting YESNO
Injury Reporting YESNO
WHMIS YESNO
Right to Refuse Work YESNO
Personal Protective Equipment YESNO
Emergency Procedures YESNO
Ladders & Scaffolds YESNO
Fall Arrest Standards YESNO
Housekeeping YESNO
Aerial Work Platforms YESNO
Confined Space Entry YESNO
Trenching & Excavating YESNO
Signs & Barricades YESNO
Cranes & Rigging YESNO
Mobile Vehicles YESNO
Hand & Power Tools YESNO
Fire Prevention & Protection YESNO
Electrical Safety YESNO
Compressed Gas Cylinders YESNO
Weather Extremes YESNO
Does your program for training newly hired or promoted SUPERVISORS include instruction of the following:
Employer Responsibilities YESNO
Employee Responsibilities YESNO
Due Diligence YESNO
Safety Leadership YESNO
Work Refusals YESNO
Inspection Processes YESNO
Incident Investigations YESNO
Safe Work Procedures YESNO
Safety Meetings YESNO
Safety Communication YESNO
First/Aid Medical Procedures YESNO
New Worker Training YESNO
Environmental Requirements YESNO
Pre-Job Safety Instruction YESNO
Drug & Alcohol Policy YESNO
Progressive Disciplinary Policy YESNO
Safe Work Practices YESNO
Notification Requirements YESNO
Note: Please attach with your submission your orientation and supervisor training documents.
SAFETY ACTIVITIES
Do you conduct safety inspections? YESNO
If “yes”, what frequency? WeeklyMonthlyQuarterlyAnnually
Does your safety inspection process include:
Participation YESNO
Corrective Action YESNO
Document Requirements YESNO
Follow-Up to Corrective Actions YESNO
Report Distribution Requirements YESNO
Does your company hold site safety meetings for field employees? YESNO
If “yes”, how frequently?
Does your company hold contractor meetings where safety is addressed with Management and Field Supervisors? YESNO
Is Pre-Job safety instructions provided before each new task? YESNO
Is the process documented? YESNO
Who leads the discussions:
Does your company have a hazard assessment process? YESNO
Does your company have a field level hazard assessment at the worker level? YESNO
Does your company have a process for evaluating higher risk activities? YESNO
Does your company have a continuous improvement process for HSSE including the following?
HSE Action Plans YESNO
Environmental Goals YESNO
Safety Alerts & Formal Company Wide Communications YESNO
Annual Safety Goals YESNO
Technology Initiatives YESNO
Fit For Duty Program YESNO
Additional Comments:
HSSE PROGRAMS, PRACTICES AND STEWARDSHIP
Are incident reports and report summaries set to the following persons, and how often?
Workforce YESNOWeekWeekQuarterAnnual
Project / Site Manager YESNOWeekWeekQuarterAnnual
Safety Director / Manager YESNOWeekWeekQuarterAnnual
Executives YESNOWeekWeekQuarterAnnual
How are incident records and cost summaries kept? (e.g.: by project, by region, etc.)
How often are incidents reported internally? WeekMonthQuarterAnnual
Does your company track non-injury incidents? YESNO
How often are they summarized and communicated, in particular as follows:
Near Miss WeekMonthQuarterAnnual
Property Damage WeekMonthQuarterAnnual
Fire WeekMonthQuarterAnnual
Security WeekMonthQuarterAnnual
Environmental WeekMonthQuarterAnnual
HSSE COMMERCIAL QUERIES
Do your employees have ready access to the OH&S Legislation? YESNO
Does your waste management system identify and address all the Provincial, Territorial, Local and Federal Governmental regulations required for the disposal of any hazardous wastes? YESNON/A
Does your company have written programs for WHIMIS/HAZCOM including MSDS/SDS for all controlled products? YESNON/A
Does your company review monthly Carrier Profiles? YESNON/A
Does your company monitor driver’s hours of work and conduct log book monitoring? YESNON/A
Is each of your workers’ required HSSE training and retraining current? YESNON/A
Does your company HSSE program included the following:
Compressed Gas Handling YESNON/A
Driving and Journey Management YESNON/A
Confined Space Entry YESNON/A
Fit for Duty (e.g. fatigue, illness, physical limits, focus, impaired, etc.) YESNON/A
Alcohol and Drug (include copy of policy or practice) YESNON/A
Working at Heights YESNON/A
Flammable Materials YESNON/A
Mechanical Hoisting and Lifting YESNON/A
Working Alone YESNON/A
Workplace Violence YESNON/A
Working with H2S (hydrogen sulfide) YESNON/A
Security YESNON/A
Lockout, Tag Out YESNON/A
Utility Clearances YESNON/A
Heat Stress / Cold Stress YESNON/A
If required by legislation or work scope, do your employees have medical examinations for: (please select N/A only if not required)
Hearing YESNON/A
Pre-employment YESNON/A
Pulmonary Function Testing YESNON/A
Vision YESNON/A
Does your company have written work practices for the following?
Hearing Conservation Testing YESNON/A
Respiratory Protection YESNON/A
If respiratory protection is required, have employees been:
- Mask Fit Tested YESNON/A
- Trained in use of Respiratory Protection Equipment (RPE) YESNON/A
- Medically approved for Class A&B chemical suits with use of RPE YESNON/A
Personal Protective Equipment (PPE)
Does your company provide applicable PPE to employees? YESNO
Does your company have a program to ensure PPE is inspected and maintained? YESNO
Are employees trained in the use, care, and limitations of PPE? YESNO
Preventative Maintenance
Does your company have a preventative maintenance program for your equipment? YESNO
Does your company have maintenance staff and/or use an external maintenance provider? YESNON/A
YOUR SUBCONTRACTORS
Your subcontractors (if no subcontractors are involved, mark N/A and skip this section) N/A
As part of the selection process, does your company evaluate the ability of subcontractors to comply with applicable HSSE requirements? YESNON/A
Does your company monitor subcontractors HSSE performance at the worksite? YESNON/A
If “yes”, please describe how this is accomplished
Does your company include your subcontractors in:
HSSE Orientation YESNO
HSSE Meetings YESNO
Audits YESNO
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KEY QA/QC PERSONNEL
*Please provide a copy of your organizational chart showing functional reporting of your quality department (Corporate, Site & Supervision). Is it attached: YESNO
Does your Company have dedicated Quality Assurance / Control personnel in the following positions?
Quality Control and Quality Assurance Manager YESNO
Field Quality Lead YESNO
Document and Records YESNO
Warehousing and Receiving YESNO
Do you have an approved quality control manual (ABSA, TSASK, etc)? If “yes”, provide an uncontrolled copy in PDF format. YESNO
Do you have a Quality Management System Manual (ISO)? If “yes”, provide an uncontrolled copy in PDF format. YESNO
Is your company ISO Certified or ISO ready? YESNO
If so, indicate the Quality Management System: ISO 9001;ISO 9002;ISO 9003;
Name of ISO Registering Body:
Expiry date of current Registration:
Does your company have a documented quality policy or a quality statement? YESNO
Are your employees motivated to achieve the defined quality objectives? YESNO
If “yes”, can you provide an example?
Does your QMS system include provisions for the use of project quality management plans (PQMP)? *Provide Sample YESNO
Does your QMS process employ the use of an inspection and test plan (ITP)? *Provide Sample YESNO
QUALITY PLANNING
Does your quality manual cover the following procedures?
ITP development and implementation YESNO
Material sourcing YESNO
Receiving and material inspection YESNO
Non-conformance reporting YESNO
Packing, storage and handling YESNO
Internal auditing process YESNO
Records and document control and retention YESNO
How often do you revise your procedures, quality manuals, and other controlled documents? NeverAnnuallyEvery 2 yrs.As required
STANDARDS AND CERTIFICATION
List codes and standards to which your company is qualified (ASME, API, ANSI, CSA, ASTM, CGSB, etc.) Include any sections/divisions e.g. CSA 47.1 Divn 2.1.
PURCHASING
Do you have a documented procedure for purchasing of materials? YESNO
Do your PO’s contain material type, class, grade, colour code, inspection documents, receiving, preservation, maintenance, specification requirements? YESNO
Do you confirm the material specifications with test certificate copies, prior to release to construction? YESNON/A
Do you maintain a list of approved suppliers? YESNO
SUPPLIER QUALITY CONTROLS
Does your company perform a quality audit on its suppliers prior to use to evaluate their ability to supply acceptable material/product? YESNO
Does your company perform quality surveillance on your suppliers? YESNO
If surveillance and quality audits are performed, are the results available to SRG for review? YESNO
Are PO’s reviewed by your quality group for compliance to specifications and drawings prior to processing? YESNO
SIGNING THIS DOCUMENT IS CONFIRMATION THAT YOU HAVE SHARED THE REQUIREMENTS HEREIN WITH THE EMPLOYEES OF YOUR ORGANIZATION WHO WILL BE WORKING FOR AND ON BEHALF OF SRG, AND THAT THE INFORMATION YOU HAVE SUPPLIED IS BOTH ACCURATE AND TRUTHFUL.
I declare that the information provided on this questionnaire is true and correct to the best of my knowledge, and open to review by SRG.
Company
Date
Name (Printed)
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Company agrees that, in order to be considered for supply to SRG (or its subsidiaries, segments or affiliates), Company must provide certain information to SRG. Company therefore agrees and consents, as a condition to its being considered for supply to SRG, to the following:
Company agrees and consents to the release to SRG, or to third parties retained by SRG to conduct investigations on its behalf, of information possessed or maintained by information sources about and concerning Company (hereafter “information sources”) which serves to support, verify or qualify answers to inquiries set forth in SRG’s 3rd Party Qual. Questionnaire Application. Such information sources will include, but are not limited to, entities with which Company maintains banking or other financial relationships, business references provided by Company, governmental or regulatory agencies and which Company has had dealings, contacts or affiliation.
By signing this document in the space set forth below, Company further agrees:
that any and all said information sources may completely and unqualifiedly on said signature of Company, without further question, inquiry or qualification, and provide to SRG such information, in writing or otherwise as reasonably requested by SRG, as is necessary for SRG to completely and thoroughly make a retention determination with respect to Company; and
o release, indemnify and hold harmless SRG, third party investigative representatives retained by SRG, as well as the information sources themselves from and against any and all claims, demands, costs, expenses, or liabilities arising from or related to, directly or indirectly, the release of said information by such information sources. This release, indemnity and hold harmless provision shall survive the termination or lapse of this Consent to Release of Information.
It is understood that SRG will use the information obtained hereby solely for the limited purpose of validating the veracity and thoroughness of information separately provided to SRG by Company, in order for SRG to make an informed decision about supply arrangements with SRG. This may involve the use by SRG of third party investigative representatives. SRG may disclose the information to the extent required by law, by any governmental or other regulatory authority (including, without limitation, any relevant stock exchange or exchange commission), or by a court or other authority of competent jurisdiction.
This Release of Information Consent is agreed to and effective as of the date written below and, except with regards to clause 3 above, shall remain in full force and effect for the latter of: 12 months hereafter or until 12 months after all work, services and product supplied to SRG is complete, at which date this Release of Information Consent shall lapse.
Signature:
Print Name:
Title/Position:
Date:
DOCUMENTS TO BE RETURNED BY COMPANY ALONG WITH THE COMPLETED QUESTIONNAIRE
Please provide the following documentation to support the responses you have provided in this questionnaire:
Release of Information Consent Form
Audited Financial Statements (last 3 years)
Void Cheque or Bank issued document, signed by Bank
Bank Details & References
Company Incorporation Certificates
Current (valid) trade registration certificates
Directors Information from Corporate Registry (or equivalent) or Lawyers Letter
Shareholders Information from Corporate Registry (or equivalent) or Lawyers Letter
Proof of Identity for Key Shareholders/Directors where your contract with SRG exceeded $2M CAD in the past calendar year You are required to supply ONE primary photo identification document from the list below If this cannot be obtained, you must supply at least ONE primary non-photo identification document and ONE secondary identification document stating the current residential address.
Primary Photo ID
Primary Non-Photo ID
Secondary ID
Driver’s License (current)
Driver’s License Permit (current)
Passport (expiry date no less than 2 years from date of submission)
National Photo ID Card (current)
Birth Certificate
Citizenship Certificate
Birth Certificate/Marriage Certificate (confirm maiden name to married name)
Tax Notice (less than 12 months old)
Utility Bill – Electricity, Telephone (landline), etc. (not more than 3 months old)
Group Structure (org chart – list all companies owned or controlled by company)
If Publically Traded; list of each shareholder holding 5% or more individually
Insurance Certificates
WCB Employer Premium Rate Statements (3 years) – for each jurisdiction
WCB Letter in Good Standing (clearance letter) – for each jurisdiction
Annually signed Health, Safety, Environmental (HSE) Policy conforming to legislation
HSE Manual including: (i) Alcohol & Drug policy; (ii) procedure to verify worker competence; (ii) investigation process.
Description of HSSE Citations (if applicable) & description of any Lost Time Injury or Fatality Identified
Recordable incident list, with corrective actions listed for past 3 years
Copy of current company Safety Organizational Chart
Copy of current company Quality Organization Structure
Quality Assurance Program Manual(s)
Project Quality Management Plan (PQMP) sample
Inspection Test Plan (ITP) sample
ISO Certificates, Governing Jurisdiction Certificates
Transportation Suppliers to provide their Carrier Profiles
Validation of Indigenous Ownership (if applicable)
Copy of your company Anti-Bribery as well as Code of Ethics Policies (if applicable)
Copy of Social Fingerprint Audit (SA8000 Standard) (if applicable)
Annual Rate Table
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