Attachment XIII - SF-330.pdf

5. NAME OF FIRM

PART I - CONTRACT-SPECIFIC QUALIFICATIONS

ARCHITECT - ENGINEER QUALIFICATIONS

A. CONTRACT INFORMATION

1. TITLE AND LOCATION (City and State)

2. PUBLIC NOTICE DATE 3. SOLICITATION OR PROJECT NUMBER

B. ARCHITECT-ENGINEER POINT OF CONTACT

C. PROPOSED TEAM

(Complete this section for the prime contractor and all key subcontractors.)

4. NAME AND TITLE

8. E-MAIL ADDRESS7. FAX NUMBER6. TELEPHONE NUMBER

(Check)

P R

IM

E

J- V

P

A R

TN

E

R S

U B

C O

N

TR

A

C

TO

R

9. FIRM NAME 10. ADDRESS 11. ROLE IN THIS CONTRACT

a.

b.

c.

d.

e.

f.

STANDARD FORM 330 (REV. 8/2016)

D. ORGANIZATIONAL CHART OF PROPOSED TEAM (Attached)

CHECK IF BRANCH OFFICE

CHECK IF BRANCH OFFICE

CHECK IF BRANCH OFFICE

CHECK IF BRANCH OFFICE

CHECK IF BRANCH OFFICE

CHECK IF BRANCH OFFICE

AUTHORIZED FOR LOCAL REPRODUCTION

12. NAME 13. ROLE IN THIS CONTRACT

18. OTHER PROFESSIONAL QUALIFICATIONS (Publications, Organizations, Training, Awards, etc.)

E. RESUMES OF KEY PERSONNEL PROPOSED FOR THIS CONTRACT

(Complete one Section E for each key person.)

14. YEARS EXPERIENCE

b. WITH CURRENT FIRMa. TOTAL

17. CURRENT PROFESSIONAL REGISTRATION (State and Discipline)16. EDUCATION (Degree and Specialization)

15. FIRM NAME AND LOCATION (City and State)

STANDARD FORM 330 (REV. 8/2016) PAGE 2

a.

b.

c.

d.

(1) TITLE AND LOCATION (City and State)

PROFESSIONAL SERVICES CONSTRUCTION (If applicable)

(1) TITLE AND LOCATION (City and State) (2) YEAR COMPLETED PROFESSIONAL SERVICES CONSTRUCTION (If applicable)

(1) TITLE AND LOCATION (City and State) (2) YEAR COMPLETED PROFESSIONAL SERVICES CONSTRUCTION (If applicable)

(1) TITLE AND LOCATION (City and State) (2) YEAR COMPLETED

PROFESSIONAL SERVICES CONSTRUCTION (If applicable) e.

Check if project performed with current firm

Check if project performed with current firm

(3) BRIEF DESCRIPTION (Brief scope, size, cost, etc.) AND SPECIFIC ROLE

(3) BRIEF DESCRIPTION (Brief scope, size, cost, etc.) AND SPECIFIC ROLE

(3) BRIEF DESCRIPTION (Brief scope, size, cost, etc.) AND SPECIFIC ROLE

Check if project performed with current firm

Check if project performed with current firm

(3) BRIEF DESCRIPTION (Brief scope, size, cost, etc.) AND SPECIFIC ROLE

19. RELEVANT PROJECTS

(1) TITLE AND LOCATION (City and State) (2) YEAR COMPLETED

PROFESSIONAL SERVICES CONSTRUCTION (If applicable)

(2) YEAR COMPLETED

(3) BRIEF DESCRIPTION (Brief scope, size, cost, etc.) AND SPECIFIC ROLE Check if project performed with current firm

F. EXAMPLE PROJECTS WHICH BEST ILLUSTRATE PROPOSED TEAM'S

QUALIFICATIONS FOR THIS CONTRACT

(Present as many projects as requested by the agency, or 10 projects, if not specified.

Complete one Section F for each project.)

a. PROJECT OWNER

21. TITLE AND LOCATION (City and State)

25. FIRMS FROM SECTION C INVOLVED WITH THIS PROJECT

24. BRIEF DESCRIPTION OF PROJECT AND RELEVANCE TO THIS CONTRACT (Include scope, size, and cost)

20. EXAMPLE PROJECT KEY

NUMBER

a.

b.

c.

d.

e.

f.

(1) FIRM NAME (2) FIRM LOCATION (City and State)

(3) ROLE(1) FIRM NAME (2) FIRM LOCATION (City and State)

(3) ROLE(1) FIRM NAME (2) FIRM LOCATION (City and State)

(3) ROLE(1) FIRM NAME (2) FIRM LOCATION (City and State)

STANDARD FORM 330 (REV. 8/2016) PAGE 3

(3) ROLE

(1) FIRM NAME (2) FIRM LOCATION (City and State) (3) ROLE

b. POINT OF CONTACT NAME

23. PROJECT OWNER'S INFORMATION

c. POINT OF CONTACT TELEPHONE NUMBER

(3) ROLE(1) FIRM NAME (2) FIRM LOCATION (City and State)

22. YEAR COMPLETED

PROFESSIONAL SERVICES CONSTRUCTION (If applicable)

TITLE OF EXAMPLE PROJECT (From Section F)

G. KEY PERSONNEL PARTICIPATION IN EXAMPLE PROJECTS

STANDARD FORM 330 (REV. 8/2016) PAGE 4

26. NAMES OF KEY

PERSONNEL

(From Section E, Block 12)

27. ROLE IN THIS

CONTRACT

(From Section E, Block 13) 1 2 3 4 5 6 7 8 9 10

29. EXAMPLE PROJECTS KEY

NUMBER TITLE OF EXAMPLE PROJECT (From Section F) NUMBER

28. EXAMPLE PROJECTS LISTED IN SECTION F

(Fill in "Example Projects Key" section below before completing table.

Place "X" under project key number for participation in same or similar role.)

H. ADDITIONAL INFORMATION

30. PROVIDE ANY ADDITIONAL INFORMATION REQUESTED BY THE AGENCY. ATTACH ADDITIONAL SHEETS AS NEEDED.

I. AUTHORIZED REPRESENTATIVE

The foregoing is a statement of facts.

31. SIGNATURE 32. DATE

33. NAME AND TITLE

STANDARD FORM 330 (REV. 8/2016) PAGE 5

PART II - GENERAL QUALIFICATIONS

(If a firm has branch offices, complete for each specific branch office seeking work.)

a. SIGNATURE

ARCHITECT-ENGINEER QUALIFICATIONS

2a. FIRM (or Branch Office) NAME

2b. STREET

2c. CITY 2d. STATE 2e. ZIP CODE

3. YEAR ESTABLISHED 4. UNIQUE ENTITY IDENTIFIER

5. OWNERSHIP

b. Discipline

c. Number of Employees

10. PROFILE OF FIRM'S EXPERIENCE

AND ANNUAL AVERAGE REVENUE FOR LAST 5 YEARS

b. Experience

c. Revenue Index

Number (see below)

STANDARD FORM 330 (REV. 8/2016) PAGE 6

1. SOLICITATION NUMBER (If any)

8a. FORMER FIRM NAME(S) (If any) 8b. YEAR ESTABLISHED

9. EMPLOYEES BY DISCIPLINE

Total

(1) FIRM (2) BRANCH

1. Less than $100,000

2. $100,000 to less than $250,000

3. $250,000 to less than $500,000

4. $500,000 to less than $1 million

5. $1 million to less than $2 million

11. ANNUAL AVERAGE PROFESSIONAL

SERVICES REVENUES OF FIRM

FOR LAST 3 YEARS

(Insert revenue index number shown at right)

7. NAME OF FIRM (If Block 2a is a Branch Office)

6a. POINT OF CONTACT NAME AND TITLE

6c. E-MAIL ADDRESS

8c. UNIQUE ENTITY IDENTIFIER

a. Federal Work

b. Non-Federal Work

c. Total Work

12. AUTHORIZED REPRESENTATIVE

The foregoing is a statement of facts.

b. DATE

c. NAME AND TITLE

a. Function Code

a. Profile Code

6b. TELEPHONE NUMBER

a. TYPE

b. SMALL BUSINESS STATUS

PROFESSIONAL SERVICES REVENUE INDEX NUMBER

6. $2 million to less than $5 million

7. $5 million to less than $10 million

8. $10 million to less than $25 million

9. $25 million to less than $50 million

10. $50 million or greater

Other Employees