158600FillableForms.pdf

IFB#_____________

ATTACHMENT A

VENDOR QUALIFICATION FORM

(ASD-08)

All bidders responding to this IFB are required to complete this form. Failure to complete this attachment may render the bid non-responsive.

1. Name of Business: _____________________________________________________________

2. Name of Owner or Chief Executive Officer: __________________________ Telephone Number: _________________

3. How many years has the firm been in the business of performing the services called for in this IFB? _________

4. How many persons are currently employed by the firm?

5. REFERENCES: Bidders should provide a list of at least 3 references where similar goods and/or services have been provided.

Each reference shall include the name of the organization, the complete mailing address, the name of the contact person, the email, and the telephone/fax number.

FIRM’S NAME AND ADDRESS CONTACT PERSON EMAIL ADDRESS TELEPHONE / FAX #

Contractor shall have an established regional or satellite office located within a 75-mile radius of 239 State Street, Rocky Mt., VA.

24151 (MapQuest will be used to verify distance). This office shall be a manned administrative office. Please indicate below the servicing office location.

CONTRACTOR’S LOCATION: _______________________________________________________________

ATTACHMENT B

Administrative Services/Procurement

State Corporation Commission Form

Failure to complete and return this attachment may result in your bid being deemed NON-RESPONSIVE.

IFB #:

Virginia State Corporation Commission (SCC) registration information.

The bidder:

is a corporation or other business entity with the following SCC identification number:

-OR-

is not a corporation, limited liability company, limited partnership, registered limited liability partnership, or business trust -OR-is an out-of-state business entity that does not regularly and continuously maintain as part of its ordinary and customary business any employees, agents, offices, facilities, or inventories in Virginia (not counting any employees or agents in Virginia who merely solicit orders that require acceptance outside Virginia before they become contracts, and not counting any incidental presence of the bidder in Virginia that is needed in order to assemble, maintain, and repair goods in accordance with the contracts by which such goods were sold and shipped into Virginia from bidder’s out-of-state location) -OR-is an out-of-state business entity that is including with this bid an opinion of legal counsel which accurately and completely discloses the undersigned bidder’s current contacts with Virginia and describes why those contacts do not constitute the transaction of business in Virginia within the meaning of § 13.1-757 or other similar provisions in Titles

13.1 or 50 of the Code of Virginia.

**NOTE** >> Check the following box if you have not completed any of the foregoing options but currently have pending before the SCC an application for authority to transact business in the Commonwealth of Virginia and wish to be considered for a waiver to allow you to submit the SCC identification number after the due date for bids (the

Commonwealth reserves the right to determine in its sole discretion whether to allow such waiver):

ATTACHMENT C

IFB# ________

NORMAL AND EMERGENCY

CONTACTS

Send Contracts To:

Bidder's Name/Title Primary Phone Number

Bidder's Mailing Address E-mail Address

Contact Person’s Name

Cellular Telephone Number

Telephone Number – Normal Work Hours

Telephone Number – After Work Hours

Fax Number

E-mail Address

Contact Person’s Name

Cellular Telephone Number

Telephone Number – Normal Work Hours

Telephone Number – After Work Hours

Fax Number

E-mail Address

Contact Person’s Name

Cellular Telephone Number

Telephone Number – Normal Work Hours

Telephone Number – After Work Hours

Fax Number

E-mail Address

Administrative Services/Procurement

IFB #:

SUBCONTRACTOR APPROVAL REQUEST

No portion of the work (including equipment) shall be subcontracted to another firm or individual without prior written consent of Virginia Department of Transportation (herein referred to as VDOT). In the event that the contractor desires to subcontract some part of the work specified herein, the contractor shall furnish VDOT with the names, qualifications, and experience of their proposed subcontractors for agency approval. The primary contractor shall, however, remain fully liable and responsible for the work performed by its subcontractor(s) and shall assure compliance with all requirements of the contract.

List proposed subcontractor(s), including name, address, contact person, and type of work to be performed under this contract below.

FIRM INDIVIDUAL’S

NAME & ADDRESS

CONTACT PERSON AND

PHONE NUMBER

TYPE OF WORK TO BE

PERFORMED

TYPE OF EQUIPMENT PROPOSED SUBCONTRACTOR WILL PROVIDE

QUALIFICATIONS / EXPERIENCE LEVEL OF PROPOSED SUBCONTRACTOR

Please indicate which above proposed subcontractors are certified (with DSBSD) as Small, Women Owned or

Minority Businesses.

Certification Number(s):

FOR VDOT USE ONLY:

The proposed subcontractor(s) listed above is/are approved and accepted under the terms and conditions of the contract requirements herein.

Signature of Authorized VDOT Representative Date Telephone Number

ATTACHMENT D