1-Attachment I - General Information.pdf

ATTACHMENT I

GENERAL INFORMATION QUESTIONNAIRE

Respondent Information: Provide the following information regarding the Respondent.

(NOTE: Co-Respondents are two or more entities proposing as a team or joint venture with each signing the contract, if awarded. Sub-Consultants are not Co-Respondents and should not be identified here.

If this Proposal includes Co-Respondents, provide the required information in this Item #1 for each

Co-Respondent by copying and inserting an additional block(s) before Item #2.)

Firm Name: __________________________________________________________________________

(NOTE: Give exact legal name as it will appear on the contract if awarded.)

Principal Address: _____________________________________________________________________

City: ______________________ State: _________________________ Zip: _________________________

Phone: _____________________ Email:__________________________

Website: ________________________________________________________ Year established: _______________

Provide the number of years in business under present name: _______________________________________________________

Social Security Number or Federal Employer Identification Number: ________________________________________________

Comptroller’s Tax Payer Number, if applicable: _____________________________________________________________

(NOTE: This 11-digit number is sometimes referred to as the Comptroller’s TIN or TID.)

Business Structure: Check the box that indicates the business structure of the Respondent.

______ Individual or Sole Proprietorship. If checked, list Assumed Name, if any: _____________________

______ Partnership _______ Corporation If checked, check one: ______ For-Profit ______Nonprofit

______ Domestic ______ Foreign

______ Other

If checked, list business structure: _________________

Printed Name of Contract Signatory: ______________________________________________________

BY: _______________________________________________________

(Signature)

TITLE: ______________________________________________________

ADDRESS: ______________________________________________________

DATE: _________________________________________________

(NOTE: This solicitation solicits Proposals to provide services under a contract which has been identified as “High Profile”. Therefore, the Respondent must provide the name of the person that will sign the contract for the Respondent, if awarded.)

1.

Provide any other names under which Respondent has operated within the last 10 years and length of time under for each:

Provide address of office from which this project would be managed:

City: State: Zip Code:

Telephone No. Fax No:

Annual Revenue: $

Total Number of Employees:

List Percentage of Employees that reside in the following:

DPSD % City of Dayton % Montgomery County % Ohio %

Briefly describe other lines of business that the company is directly or indirectly affiliated with:

List Related Companies:

2. Contact Information: List the one person who DPSD may contact concerning your qualifications or setting dates for meetings.

Name: ____________________________ Title: _______________________________

Office Phone: _____________________ Cell Phone: __________________________

Email: ____________________________________________________

3. Does Respondent anticipate any mergers, transfer of organization ownership, management reorganization, or departure of key personnel within the next twelve (12) months?

Yes __________ No ___________

4. Is the Respondent authorized and/or licensed to do business in Ohio?

Yes __________ No ___________

If “Yes”, list authorizations/licenses.

5. Where is the Respondent’s corporate headquarters located?

6. Local/County Operation: Does the Respondent have an office located in Dayton, Ohio?

Yes No

If “Yes”, respond to a and b below:

a. How long has the Respondent conducted business from its Dayton office?

Years Months

b. Choose only one (1) Is the firm headquartered in the following:

DPSD? City of Dayton Montgomery County Ohio_

7. Debarment/Suspension Information: Has the Respondent or any of its principals been debarred or suspended from contracting with any public entity?

Yes No

If “Yes”, identify the public entity and the name and current phone number of a representative of the public entity familiar with the debarment or suspension, and state the reason for or circumstances surrounding the debarment or suspension, including but not limited to the period of time for such debarment or suspension.

8. Disciplinary Action: Has the Respondent ever received any disciplinary action, or any pending disciplinary action, from any regulatory bodies or professional organizations? Yes _ No

If “Yes”, state the name of the regulatory body or professional organization, date and reason for disciplinary or impending disciplinary action.

9. Previous Contracts:

a. Has the Respondent ever failed to complete any contract awarded?

Yes No

If “Yes”, state the name of the organization contracted with, services contracted, date, contract amount and reason for failing to complete the contract.

b. Has any officer or partner proposed for this assignment ever been an officer or partner of some other organization that failed to complete a contract?

Yes No _

If “Yes”, state the name of the individual, organization contracted with, services contracted, date, contract amount and reason for failing to complete the contract.

c. Has any officer or partner proposed for this assignment ever failed to complete a contract handled in his or her own name?

Yes No

If “Yes”, state the name of the individual, organization contracted with, services contracted, date, contract amount and reason for failing to complete the contract.