15-05 Contractor’s Qualification Statement incl Subcontractor Certification.pdf

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3. CONTRACTOR’S QUALIFICATION STATEMENT INCLUDING SUBCONTRACTOR

CERTIFICATION

This form must be completed and submitted along with proposal. (Note: Attach separate sheets as required.)

The undersigned certified the truth and correctness of all statements and of all answers to questions made hereinafter.

TO: Whitpain Township 960 Wentz Road Blue Bell, PA 19422

Submitted by: Corporation

Name: Partnership

Address: Individual

Principal Office: Joint Venture

Other

How many years has your organization been in business as a Contractor?

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

If a corporation, answer the following:

1) Date of incorporation:

2) State of incorporation:

3) President’s name:

4) Vice President’s name(s):

5) Secretary or Clerk’s name:

6) Treasurer’s name:

7) List name and address of all parties holding greater than ten percent (10%) interest in the corporation:

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If individual or partnership, answer the following:

1) Date of origination:

2) Name and address of all partners (State whether general or limited partnership):

If other than corporation or partnership, describe organization and name principals:

We normally perform ____% of the Work with our own forces. List trades below:

Have you ever failed to complete any Work awarded to you? If so, note when, where and why:

Has any officer or partner of your organization ever been an officer or partner of another organization that failed to complete a construction Contract? If so, state circumstances:

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List name of project, Owner, architect, Contract amount, percent complete and scheduled Completion of the comparable construction projects your organization has in progress on this date:

List name of project, Owner, architect, Contract amount, date of Completion, percent or Work with own forces of the projects your organization has completed in the past two (2) years which equal at least fifty percent (50%) of the total amount of the Bid for the project under consideration:

List the construction experience of the principal individuals of your organization:

List the categories in which your organization is legally qualified to do business in Pennsylvania:

Trade References:

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Bank References:

Name of Bonding Company and name and address of agent:

Dated at this day of , 20 .

Name of Organization:

By:

Title:

M , being duly sworn, deposes and says that he/she is the of Contractor(s), and that answers to the foregoing questions and all statements therein contained are true and correct.

Subscribed and sworn before me this day of , 20 .

Notary Public:

My Commission Expires:

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SUBCONTRACTOR CERTIFICATION

This form must be completed and submitted along with proposal

___________________________, having submitted a Bid for the SR 73, SEC. MT2 (MPMS #81892): Skippack Pike (SR 0073) and School Road (SR 2016) Improvement Project, hereby certifies:

1) That he/she has listed below the complete names, addresses and business license numbers of all subcontractors, including lower tier subcontractors, if any, whose services he/she intends to use in performing all work on the above project.

2) That, if he/she is awarded the above Contract, he/she will not substitute another contractor for any subcontract listed below, nor allow the substitution of another lower tier subcontractor for any lower tier subcontractor listed below, for the performance of any work under this contract, without written approval of Whitpain Township.

Subcontractor Trade: Name, Address, & Business License No. of Subcontractor:

(1)_____________________ _______________________________________________ (2)_____________________ _______________________________________________ (3)_____________________ _______________________________________________ (4)_____________________ _______________________________________________

(5)_____________________ _______________________________________________

* Notes: (1) Include all subcontractors, including lower tiers

(2) If any subcontractor is a minority firm, so indicate (for additional listings, use separate sheet and insert herein)

3) That he/she has informed or caused to be informed all subcontractors listed above, including lower tier subcontractors, of their obligation to comply with all applicable provisions of Federal and State law, and the requirement for their compliance with these provisions, as applicable, upon Award of Contract.

(date) (name of bidder) (signature of authorized representative) (printed name and title of signer)