12-10 - Exhibit L - 33-253.pdf

Solicitation No.

FORM 33.253-PF (02/24) Page 1 of 4 Exhibit L

Dallas Area Rapid Transit

EXHIBIT L

BUSINESS QUESTIONNAIRE

(SUPPLIES and SERVICES)

This questionnaire, the requested list of references, and the authorization to release financial information are used in part to assist in determining a potential contractor’s responsibility. Offerors shall submit the Exhibit L information within two (2) work days from the date of notification by the Authority, or with the offer, if so indicated in the Table of Contents page 2 of the Solicitation, Offer and Award Form, and in accordance with applicable provision(s) in Exhibit B, if any. All information must be current and traceable. Each venturer of a joint venture must submit a separate signed form.

DART reserves the right to make additional inquiries based on information submitted, or the lack thereof.

Questions concerning this questionnaire or the authorization form should be directed to the contact person identified on the Solicitation, Offer and Award Form.

NOTE: Questions marked with an asterisk ("*") require a response.

1. *Name of Offeror ("Business"): ___________________________________________________

2. *List name(s) and business address of officers and directors for corporations, partners for partnerships, and venturers for joint ventures (attach additional pages as necessary).

3. *Number of years in business under present business name: _________

4. If applicable, list all other names under which the Business identified above operated in the last 5 years.

5. *Annual Gross Revenue (Past year): (M represents millions, K represents thousands) $100K or less $100K-$500K $500K-$1M $1M-$5M $5M-$10M $10M-$16M $16M or Over

6. *Current number of employees: __________

7. *Has the Business, or any officer or partner thereof, failed to complete a contract?

8. *Is there any pending or current litigation against the business?

9. *Has there been any outcome of litigation or claims against the business in the last five years?

Yes No

10. *Has any officer or executive of the business been convicted or is under indictment for a felony?

Yes No

11. *Has the Business ever been declared "not responsible" for the purpose of any governmental agency contract award?

Yes No

Yes No

Yes No

FORM 33.253-PF (02/24) Page 2 of 4 Exhibit L

13. *Are there any proceedings pending relating to the Business' responsibility, debarment, suspension, voluntary exclusion, or qualification to receive a public contract?

Yes No

14. *Has the government or other public entity requested or required enforcement of any of its rights

Yes No

15. *Is the Business in arrears on any contract or debt?

No

17. *Have liquidated damages or penalty provisions been assessed against the Business for failure to complete work on time or for any other reason?

18. If a "Yes" response is given under questions 7 through 17, please provide a detailed explanation including dates, reference to contract information, contacts, etc. (attach additional pages as necessary).

I, individually and on behalf of the business named in this Business Questionnaire, do by my signature below, certify that the information provided in this questionnaire is true and correct. I understand that any false statements or misrepresentations regarding the Business named above may result in: 1) termination of any or all contracts which DART has or may have with the Business; 2) disqualification of the Business from consideration for contracts; 3) removal of the Business from DART’s bidders’ list;

or/and 4) legal action(s) applicable under federal, state, or local law. I also understand that if awarded a contract under this solicitation, I am responsible for updating this Exhibit L noting any changes within ten days following the change.

Name: ________________________________________

Signature: _____________________________________ (Owner, CEO, President, Majority Stockholder or Designated Representative)

Yes

Yes No

Yes No

Solicitation No.

12. *Has the Business been debarred, suspended, proposed for debarment, declared ineligible, voluntarily excluded, or otherwise disqualified from bidding, proposing, or contracting?

Yes No mm/dd/yyyy under a surety agreement on the basis of a default or in lieu of declaring the Business in default?

16. *Has the Business been a defaulter, as a principal, surety or otherwise?

Title: ___________________________

Date: _______________

FORM 33.253-PF (02/24) Page 3 of 4 Exhibit L

LIST OF REFERENCES FOR SIMILAR PROJECTS

A minimum of two references is required.

Use additional pages as necessary.

Solicitation No.

1. *Project: ________________________________ Date of Completion (if applicable): ___________ mm/dd/yyyy

*Contact Person: ______________________ *Company Name: ________________________________ Address: _________________________________________________________ Telephone Number: ______________ Fax Number: ______________ *E-mail Address: ___________________________

2. *Project: ________________________________ Date of Completion (if applicable): ___________ mm/dd/yyyy *Contact Person: ______________________ *Company Name: ________________________________ Address: _________________________________________________________ Telephone Number: ______________ Fax Number: ______________ *E-mail Address: ___________________________

3. *Project: ________________________________ Date of Completion (if applicable): ___________ mm/dd/yyyy *Contact Person: ______________________ *Company Name: ________________________________ Address: _________________________________________________________ Telephone Number: ______________ Fax Number: ______________ *E-mail Address: ___________________________

4. *Project: ________________________________ Date of Completion (if applicable): ___________ mm/dd/yyyy *Contact Person: ______________________ *Company Name: ________________________________ Address: _________________________________________________________ Telephone Number: ______________ Fax Number: ______________ *E-mail Address: ___________________________

Check if additional references provided.

FORM 33.253-PF (02/24 Page 4 of 4 Exhibit L

Dallas Area Rapid Transit

AUTHORIZATION FOR RELEASE OF FINANCIAL INFORMATION

This authorization will be used to obtain information to assist DART in determining a potential contractor’s financial responsibility. Your signature authorizes the release of financial information to the DART Procurement Department for this purpose. All information must be current and traceable. Each venturer of a joint venture must submit a separate signed form.

This authorization form shall be submitted in accordance with the applicable provision(s) in Exhibit B, or as otherwise requested. DART reserves the right to make additional inquiries based on information submitted, or the lack thereof.

Name of Bank/Financial Institution

Account Number

Street Address of Bank/Financial Institution

Account Type: e.g., Savings, Checking, Other (Identify)

Name of Bank Officer Familiar with the Account

Telephone Fax

Email Address

Name of Business (with bank) Business Street Address

City State / Province ZIP / Postal Code

I, individually and on behalf of the Business named above, do by my signature below, certify that the information provided is true and correct, and authorize the release of financial information for verification of financial responsibility. I understand that any false statements or misrepresentations regarding the Business named above may result in: 1) termination of any or all contracts which DART has or may have with the business; 2) disqualification of the Business from consideration for contracts; 3) removal of the Business from DART’s bidders list; or/and 4) legal action(s) applicable under federal, state or local law.

Name: _______________________________________

Signature: ____________________________________

Title: ___________________________

Date: _______________

Solicitation No.

(Owner, CEO, President, Majority Stockholder or Designated Representative)

State / Province ZIP / Postal Code City mm/dd/yyyy

NHoward Sticky Note Completed set by NHoward

NHoward Sticky Note Completed set by NHoward

NHoward Sticky Note Completed set by NHoward

NHoward Sticky Note Accepted set by NHoward

NHoward Sticky Note Accepted set by NHoward