10-26-204JH - Proposers Qualification Statement.pdf

PROPOSER’S QUALIFICATION STATEMENT

The undersigned certifies under oath the truth and correctness of all statements and of all answers to questions made hereinafter:

SUBMITTED TO: SOLID WASTE AUTHORITY OF PALM BEACH COUNTY

PURCHASING SERVICES DEPARTMENT

7501 N. Jog Road West Palm Beach, FL. 33412

Check One Submitted by: Corporation:

Name: _____________________________________________ Partnership:

Address: ____________________________________________ Individual:

City, State, Zip: ______________________________________ Other* Federal Identification Number (FID) ______________________ ( * if other is being checked, please provide supporting documentation to validate the legality of the Firm)

1. State the true, exact, correct and complete name of the partnership, trade or fictitious name under which you do business and the address of the place of business.

The correct name of the PROPOSER is:

The address of the headquarters/ permanent office/ principal place of business is:

2. If PROPOSER is corporation, answer the following:

a. Date of Incorporation: __________________________________________

b. State of Incorporation: __________________________________________

c. President’s name: _____________________________________________

d. Vice President’s name: _________________________________________

e. Secretary’s name: _____________________________________________

f. Treasurer’s name: _____________________________________________

g. Name and Address of Resident Agent: _____________________________

3. If PROPOSER is an individual or a partnership, answer the following:

a. Date of organization: _______________________

b. Name, address and ownership units of all partners:

c. State whether general or limited partnership: ________________________

4. If PROPOSER is other than an individual, corporation or partnership, describe the organization and give the name and address of principals:

5. If PROPOSER is operating under a fictitious name, submit evidence of compliance with the Florida

Fictitious Name Statute.

6. How many years has your organization been in business under its present business name?

Under what other former names has your organization operated?

7. Indicate registration, license numbers or certificate numbers for the businesses or professions, which are the subject of this RFP solicitation. Please attach certificate of competency and/or state registration.

8. Provide a narrative of Firm’s Safety Program, Quality Assurance/Quality Control Management methods.

9. List and describe all bankruptcy petitions (voluntary or involuntary) which have been filed by or against the PROPOSER, its parent or subsidiaries or predecessor organizations during the past five (5) years.

Include in the description, the disposition of each such petition.

10. A list of all enforcement actions against the facility for the last three (3) years including any consent orders entered, notices of violations received, and any judgments against the facility. Also, list the amount of any fines, penalties, or judgments, or other infractions in which the destination facility or facilities have received in the most current three (3) years of operation.

11. List and describe any disciplinary action, administrative proceeding, malpractice claim or other like proceeding against your Firm or any of its lawyers, whether current or pending, as well as any such action, proceeding or claim occurring during the last five (5) years.

12. Has the PROPOSER, its principals, officers or predecessors’ organization(s) been CONVICTED of a

Public Entity Crime, debarred or suspended from bidding by any governmental entity during the last five (5) years? If so, provide details.

13. Has the PROPOSER in the past four (4) years, been rendered a final adjudicated determination in a legal or administrative proceeding in the State of Florida that the PROPOSER discriminated against its subcontractors, vendors, suppliers or commercial customers? If yes, PROPOSER shall provide a list of all instances to include but not limited to; description of the status or resolution of the complaint, including any remedial action taken. (Attach additional sheets as necessary)

The PROPOSER acknowledges and understands that the information contained in response to this Qualifications’ Statement shall be relied upon by the Solid Waste Authority of Palm Beach County (AUTHORITY), in awarding the contract and such information is warranted by PROPOSER to be true. The discovery of any omission or misstatement that materially affects the PROPOSER’s qualifications to perform under the contract shall cause the AUTHORITY to reject the proposal, and if after the award, to cancel and terminate the award and/or contract.

(Signed): _______________________________________

(Printed Name): ________________________________________

(Title): _______________________________________