00451 Qualifications Statement.pdf

Galeton Borough Authority Wetmore Run Well Development

2026-W1, 2026-W2 & 2026-W3

CEI File No. 25001215.056B 00451-1 QUALIFICATIONS STATEMENT

SECTION 00451

QUALIFICATION STATEMENT

STATEMENT OF BIDDER'S/CONTRACTOR/SUBCONTRACTOR QUALIFICATIONS

It is the intent of this form that prime bidders on prime or combination contracts complete this form in its entirety along with any attachments and enclose it with their bids. Unless otherwise required by the bidding or contract documents that Subcontractors be identified before or during the bidding process and subcontractor qualifications be submitted prior to bid or during bid opening, then this form must be submitted by all proposed Subcontractors and qualifications approved by the Owner prior to award of subcontracts to prospective Subcontractors. All questions must be answered and the data given must be clear and comprehensive. If necessary, questions may be answered on separate attached sheets. The Bidder/Contractor/Subcontractor may submit any additional information they desire. This statement must be notarized.

ARTICLE 1—GENERAL INFORMATION

1.01 Provide contact information for the Business:

Legal Name of Business:

Bidder/Contractor/Subcontractor Employer Identification Number

(EIN):

Bidder/Contractor/Subcontractor Contractor Registration Number

(CRN):

Corporate Office

Name: Phone number:

Title: Email address:

Business address of corporate office:

Local Office

Name: Phone number:

Title: Email address:

Business address of local office:

How many years have you been engaged in the contracting business under your present firm or trade name?

CEI File No. 25001215.056B 00451-2 QUALIFICATIONS STATEMENT

1.02 Provide information on the Business’s organizational structure:

Form of Business: ☐ Sole Proprietorship ☐ Partnership ☐ Corporation

☐ Limited Liability Company ☐ Joint Venture comprised of the following companies:

1.

2.

3.

Provide a separate Qualification Statement for each Joint Venturer.

Date Business was formed: State in which Business was formed:

Is this Business authorized to operate in the Project location? ☐ Yes ☐ No ☐ Pending

Predecessor Business Name (if any):

1.03 Identify all businesses that own Business in whole or in part (25% or greater), or that are wholly or partly (25% or greater) owned by Business:

Name of business: Affiliation:

Address:

Name of business: Affiliation:

Address:

Name of business: Affiliation:

Address:

1.04 Provide information regarding the Business’s officers, partners, and limits of authority.

Name: Title:

Authorized to sign contracts: ☐ Yes ☐ No Limit of Authority: $

Name: Title:

Authorized to sign contracts: ☐ Yes ☐ No Limit of Authority: $

Name: Title:

Authorized to sign contracts: ☐ Yes ☐ No Limit of Authority: $

Name: Title:

CEI File No. 25001215.056B 00451-3 QUALIFICATIONS STATEMENT

ARTICLE 2—LICENSING

2.01 Provide information regarding licensure for Business:

Name of License:

Licensing Agency:

License No: Expiration Date:

Name of License:

Licensing Agency:

License No: Expiration Date:

ARTICLE 3—DIVERSE BUSINESS CERTIFICATIONS

3.01 Provide information regarding Business’s Diverse Business Certification, if any.

Provide evidence of current certification.

Certification Certifying Agency Certification Date

☐ Disadvantaged Business Enterprise

☐ Minority Business Enterprise

☐ Woman-Owned Business Enterprise

☐ Small Business Enterprise

☐ Disabled Business Enterprise

☐ Veteran-Owned Business Enterprise

☐ Service-Disabled Veteran-Owned Business

☐ HUBZone Business (Historically Underutilized) Business

☐ Other

☐ None

CEI File No. 25001215.056B 00451-4 QUALIFICATIONS STATEMENT

ARTICLE 4—SAFETY

4.01 Provide information regarding Business’s safety organization and safety performance.

Name of Business’s Safety Officer:

Safety Certifications

Certification Name Issuing Agency Expiration

4.02 Provide Worker’s Compensation Insurance Experience Modification Rate (EMR), Total Recordable Frequency Rate (TRFR) for incidents, and Total Number of Recorded Manhours (MH) for the last 5 years and the EMR, TRFR, and MH history for the last 5 years of any proposed Subcontractor(s) that will provide Work valued at 10% or more of the Contract Price. Provide documentation of the EMR history for Business and Subcontractor(s). Attach Experience Modification Rating report form from insurer(s) for the previous 5 reporting periods for all states worked in. Attach edited OSHA 300 form for period from the date of the most recent Experience Rating. Blacken out individual names of employees on the OSHA 300 form to preserve employee privacy.

Year

Company EMR TRFR MH EMR TRFR MH EMR TRFR MH

Year

Company EMR TRFR MH EMR TRFR MH

CEI File No. 25001215.056B 00451-5 QUALIFICATIONS STATEMENT

ARTICLE 5—FINANCIAL

5.01 Provide information regarding the Business’s financial stability. Provide the most recent audited financial statement, and if such audited financial statement is not current, also provide the most current financial statement. (Unless otherwise required, this item to be completed only by bidders, not applicable to subcontractors).

Financial Institution:

Business address:

Contact Person Name:

Contact Person Phone:

Contact Person email:

Date of Business’s most recent financial statement: ☐ Attached Date of Business’s most recent audited financial statement: ☐ Attached

Financial indicators from the most recent financial statement

Contractor’s Current Ratio (Current Assets ÷ Current Liabilities)

Contractor’s Quick Ratio ((Cash and Cash Equivalents + Accounts Receivable + Short Term Investments) ÷ Current Liabilities)

Amount of Financing/Credit Available:

CEI File No. 25001215.056B 00451-6 QUALIFICATIONS STATEMENT

ARTICLE 6—SURETY INFORMATION

6.01 Provide information regarding the surety company that will issue required bonds on behalf of the Business, including but not limited to performance and payment bonds. (Unless otherwise required, this item to be completed only by bidders, not applicable to subcontractors).

Surety Name:

Surety is a corporation organized and existing under the laws of the state of:

Is surety authorized to provide surety bonds in the Project location? ☐ Yes ☐ No

Is surety listed in “Companies Holding Certificates of Authority as Acceptable Sureties on Federal Bonds and as Acceptable Reinsuring Companies” published in Department Circular 570 (as amended) by the Bureau of the Fiscal Service, U.S. Department of the Treasury?

☐ Yes ☐ No Mailing Address (principal place of business):

Physical Address

Phone (main): Phone

(claims):

CEI File No. 25001215.056B 00451-7 QUALIFICATIONS STATEMENT

ARTICLE 7—INSURANCE

7.01 Provide information regarding Business’s insurance company(s), including but not limited to its Commercial General Liability carrier. Provide information for each provider.

Name of insurance provider, and type of policy (CLE, auto, etc.):

Insurance Provider Type of Policy (Coverage Provided)

Are providers licensed or authorized to issue policies in the Project location? ☐ Yes ☐ No

Does provider have an A.M. Best Rating of A-VII or better? ☐ Yes ☐ No Mailing Address

Physical Address

(main):

(claims):

ARTICLE 8—CONSTRUCTION EXPERIENCE

8.01 Provide information that will identify the overall size and capacity of the Business.

Average number of current full-time employees:

Estimate of revenue for the current year:

Estimate of revenue for the previous year:

CEI File No. 25001215.056B 00451-8 QUALIFICATIONS STATEMENT

8.02 Provide information regarding the Business’s previous contracting experience.

Years of experience with projects like the proposed project:

As a general contractor: As a joint venturer:

Has Business, or a predecessor in interest, or an affiliate identified in Paragraph 1.03 or an proposed or engaged subcontractor or supplier:

Been disqualified as a bidder by any local, state, or federal agency within the last 5 years?

Y N Been notified of, barred or suspended, or in litigation for debarment or suspension from contracting by any local, state, or federal agency within the last 5 years?

Y N Been released from a bid in the past 5 years? ☐ Yes ☐ No

Defaulted on a contract or project or failed to complete any contract awarded to it?

☐ Yes ☐ No

Refused to construct or refused to provide materials defined in the contract documents or in a change order? ☐ Yes ☐ No

Been a party as either plaintiff, defendant, claimant or respondent to any previous or currently pending litigation or arbitration? ☐ Yes ☐ No

Provide full details in a separate attachment if the response to any of these questions is Yes.

8.03 List all projects currently under contract in Schedule A and provide indicated information.

8.04 List a minimum of three and a maximum of six projects completed in the last 5 years in Schedule B and provide indicated information to demonstrate the Business’s experience with projects similar in type and cost of construction.

8.05 In Schedule C, provide information on key individuals whom Business intends to assign to the Project. Provide resumes for those individuals included in Schedule C. Key individuals include the Project Manager, Project Superintendent, Quality Manager, and Safety Manager. Resumes may be provided for Business’s key leaders as well.

ARTICLE 9—REQUIRED ATTACHMENTS

9.01 Provide the following information with the Statement of Qualifications:

A. If Business is a Joint Venture, separate Qualifications Statements for each Joint Venturer, as required in Paragraph 1.02.

B. Diverse Business Certifications if required by Paragraph 3.01.

C. Certification of Business’s safety performance if required by Paragraph 4.02.

D. Financial statements as required by Paragraph 5.01.

E. Attachments providing additional information as required by Paragraph 8.02.

F. Schedule A (Current Projects) as required by Paragraph 8.03.

G. Schedule B (Previous Experience with Similar Projects) as required by Paragraph 8.04.

CEI File No. 25001215.056B 00451-9 QUALIFICATIONS STATEMENT

H. Schedule C (Key Individuals) and resumes for the key individuals listed, as required by Paragraph 8.05.

I. Additional items as pertinent:

1. List your major equipment available for this contract (Use separate sheet(s) or inventory listing).

2. Will you, if awarded a prime or subcontract comply with, and require by written subcontract that all of your subcontractors comply with, Act 127 of 2012 that requires registration with U.S. Department of Homeland Security, U.S. Citizenship and Immigration Service for participation in the "free" internet based E-verify System to determine the eligibility of their employees to work in the United States? YES__________ / NO__________. Furthermore, will you, as well as all subcontractors, provide completed and signed Public Works Employment Verification Form as available from the Pennsylvania Department of General Services website? YES__________ / NO__________.

CEI File No. 25001215.056B 00451-10 QUALIFICATIONS STATEMENT

The undersigned hereby authorizes and requests any person, firm, or corporation to furnish any information requested by the Local Public Agency or Project Owner in verification of the recitals comprising this statement of Bidder's / Contractor / Subcontractor Qualifications. The undersigned certifies for itself, it has no unsatisfied tax liabilities or other Federal, State, Commonwealth or local obligations. This Statement of Qualifications is offered by:

Business:

(typed or printed name of organization)

By:

(individual’s signature)

Name:

(typed or printed)

Title:

(typed or printed)

Date:

(date signed)

(If Business is a corporation, a partnership, or a joint venture, attach evidence of authority to sign.)

Attest:

(individual’s signature)

Name:

(typed or printed)

Title:

(typed or printed) Address for giving notices:

Designated Representative:

Name:

(typed or printed)

Title:

(typed or printed)

Address:

Phone:

Email:

CEI File No. 25001215.056B 00451-11 QUALIFICATIONS STATEMENT

Subscribed and sworn to before me this ____________ day of _______________, 20_____.

(TITLE)

My Commission expires: . NOTARY SEAL REQUIRED HERE

2026-W1, 2026-W2 & 2026-W3

CEI File No. 25001215.056B Page 1 of 4 QUALIFICATIONS STATEMENT-SCHEDULE B

Schedule A—Current Projects

Project Owner Project General Description of Project Cost Date Project Key Project Personnel Project Manager Project Superintendent Safety Manager Quality Control Manager Name Reference Contact Information (listing names indicates approval to contacting the names individuals as a reference) Name Title/Position Organization Telephone Email Owner Designer Construction Manager

Project Owner Project General Description of Project Cost Date Project Key Project Personnel Project Manager Project Superintendent Safety Manager Quality Control Manager Name Reference Contact Information (listing names indicates approval to contacting the names individuals as a reference) Name Title/Position Organization Telephone Email Owner Designer Construction Manager

Project Owner Project General Description of Project Cost Date Project Key Project Personnel Project Manager Project Superintendent Safety Manager Quality Control Manager Name Reference Contact Information (listing names indicates approval to contacting the names individuals as a reference) Name Title/Position Organization Telephone Email Owner Designer Construction Manager

2026-W1, 2026-W2 & 2026-W3

CEI File No. 25001215.056B Page 2 of 4 QUALIFICATIONS STATEMENT-SCHEDULE B

Schedule B—Previous Experience with Similar Projects Project Owner Project General Description of Project Cost Date Project Key Project Personnel Project Manager Project Superintendent Safety Manager Quality Control Manager Name Reference Contact Information (listing names indicates approval to contacting the names individuals as a reference) Name Title/Position Organization Telephone Email Owner Designer Construction Manager

Project Owner Project General Description of Project Cost Date Project Key Project Personnel Project Manager Project Superintendent Safety Manager Quality Control Manager Name Reference Contact Information (listing names indicates approval to contacting the names individuals as a reference) Name Title/Position Organization Telephone Email Owner Designer Construction Manager

Project Owner Project General Description of Project Cost Date Project Key Project Personnel Project Manager Project Superintendent Safety Manager Quality Control Manager Name Reference Contact Information (listing names indicates approval to contacting the names individuals as a reference) Name Title/Position Organization Telephone Email Owner Designer

2026-W1, 2026-W2 & 2026-W3

CEI File No. 25001215.056B Page 3 of 4 QUALIFICATIONS STATEMENT-SCHEDULE B

Schedule B—Previous Experience with Similar Projects Project Owner Project General Description of Project Cost Date Project Key Project Personnel Project Manager Project Superintendent Safety Manager Quality Control Manager Name Reference Contact Information (listing names indicates approval to contacting the names individuals as a reference) Name Title/Position Organization Telephone Email Owner Designer Construction Manager

Project Owner Project General Description of Project Cost Date Project Key Project Personnel Project Manager Project Superintendent Safety Manager Quality Control Manager Name Reference Contact Information (listing names indicates approval to contacting the names individuals as a reference) Name Title/Position Organization Telephone Email Owner Designer Construction Manager

Project Owner Project General Description of Project Cost Date Project Key Project Personnel Project Manager Project Superintendent Safety Manager Quality Control Manager Name Reference Contact Information (listing names indicates approval to contacting the names individuals as a reference) Name Title/Position Organization Telephone Email Owner Designer

CEI File No. 25001215.056B Page 4 of 4 QUALIFICATIONS STATEMENT-SCHEDULE B

2026-W1, 2026-W2 & 2026-W3

CEI File No. 25001215.056B Page 1 of 2 QUALIFICATIONS STATEMENT-SCHEDULE C

Schedule C—Key Individuals

Project Manager Name of individual Years of experience as project manager Years of experience with this organization Number of similar projects as project manager Number of similar projects in other positions Current Project Assignments Name of assignment Percent of time used for this project Estimated project completion date

Reference Contact Information (listing names indicates approval to contact named individuals as a reference) Name Name Title/Position Title/Position Organization Organization Telephone Telephone Email Email Project Project Candidate’s role on project

Candidate’s role on project

Project Superintendent Name of individual Years of experience as project superintendent Years of experience with this organization Number of similar projects as project superintendent Number of similar projects in other positions Current Project Assignments Name of assignment Percent of time used for this project

Name Name Title/Position Title/Position Organization Organization Telephone Telephone Email Email Project Project Candidate’s role on project

Candidate’s role on

Safety Manager

2026-W1, 2026-W2 & 2026-W3

CEI File No. 25001215.056B Page 2 of 2 QUALIFICATIONS STATEMENT-SCHEDULE C

Name of individual Years of experience as project manager Years of experience with this organization Number of similar projects as project manager Number of similar projects in other positions Current Project Assignments Name of assignment Percent of time used for this project

Name Name Title/Position Title/Position Organization Organization Telephone Telephone Email Email Project Project Candidate’s role on project

Candidate’s role on

Quality Control Manager Name of individual Years of experience as project superintendent Years of experience with this organization Number of similar projects as project superintendent Number of similar projects in other positions Current Project Assignments Name of assignment Percent of time used for this project

Name Name Title/Position Title/Position Organization Organization Telephone Telephone Email Email Project Project Candidate’s role on project

Candidate’s role on