CONTRACTOR'S QUALIFICATION FORM Attachment C

TEXAS DEPARTMENT OF CRIMINAL JUSTICE CONTRACTOR'S

CONTRACTS & PROCUREMENT Qualifications

TWO FINANCIAL PLAZA STE. 703

HUNTSVILLE, TEXAS 77340

PHONE (936) 437-3855 TDCJ PROJECT NO.

TAX PAYER ID NO.

Name of Firm and address with zip code on the above lines.

Corporation Partnership Individual Date Area Code and Telephone

Fax Number CONSTRUCTION CAPABILITIES General Electrical Plumbing

HVAC Fire Sprinkler Other

BUSINESS OWNERSHIP INFORMATION

VetHUB? Yes No If yes, State-VetHUB Certification Number

SMALL BUSINESS Yes No

FOR CORPORATION ONLY

Date of Incorporation Name of State(s) in which Incorporated

If not Incorporated in Texas, give Certificate of Authority to do business in Texas Certificate No. Date

President's Name Vice President's Name

Secretary's Name Treasurer's Name

FOR PARTNERSHIP ONLY

Is the partnership: General Limited Association Date of Organization

Names and addresses of all partners with zip codes on the above lines (use additional sheet if necessary.)

Percent (%) of work done by own staff No. of permanent employees Geographical limits of operation

No. years in business If you have done business under different name please give name and location

Has Firm ever failed to complete project or defaulted on a contract? If so, state where and why on the above lines.

Has Firm ever had any contracts that have been cancelled or terminated within the past five years? If so, state where and why on the above lines.

Has Firm or subsidiaries ever filed or met criteria for bankruptcy within the past five years? If so, state where and why on the above lines.

Has Firm ever been engaged in litigation over any contract? If so, explain on the above lines.

GENERAL INFORMATION

Questions or concerns regarding this transaction or service should be directed to: Texas Department of Criminal Justice, Contracts & Procurement Two Financial Plaza, Ste. 703, Phone (936) 437-3855.

696-FD-26-Q040 Page 1 of 6

Attachment C

PRESENT PROJECTS

List the major construction projects your firm has underway on this date: (State responsibility as Prime or Subcontractor on each)

Project Prime Owner Phone A/E Phone Contract Percent Scheduled Subcontractor No. No. Amount Complete Completion

COMPLETED PROJECTS

Municipal, State and Federal Projects:

Project Prime Owner Phone A/E Phone Contract Scheduled Actual Subcontractor No. No. Amount Comp. Date Comp. Date

Other Projects:

List the major construction projects your firm has completed in the past five years, particularly including comparable projects (Note, you may use additional page, printed matter, etc., as long as the information requested is incorporated):

696-FD-26-Q040 Page 2 of 6

Insert Name/Description of Project Here Original Days Adds Scheduled Start Actual Start

Scheduled Completion

Actual Completion

Contract Time Explanatory Note

Insert Name/Description of Project Here Original Days Adds Scheduled Start Actual Start

Scheduled Completion

Actual Completion

Contract Time Explanatory Note

Insert Name/Description of Project Here Original Days Adds Scheduled Start Actual Start

Scheduled Completion

Actual Completion

Contract Time Explanatory Note

Insert Name/Description of Project Here Original Days Adds Scheduled Start Actual Start

Scheduled Completion

Actual Completion

Contract Time Explanatory Note

Insert Name/Description of Project Here Original Days Adds Scheduled Start Actual Start

Scheduled Completion

Actual Completion

Contract Time Explanatory Note

Construction Phase

Construction Phase

SCHEDULE COMPLIANCE

Construction Phase

Construction Phase

Construction Phase

696-FD-26-Q040 Page 3 of 6

Insert Name/Description of Project Here Comments:

Contract Award $ -

Changes $ - Final Contract Amount $ - Percent Changes $ -

Insert Name/Description of Project Here Comments:

Contract Award $ -

Changes $ - Final Contract Amount $ -

Percent Changes $ -

Insert Name/Description of Project Here Comments:

Contract Award $ - Changes $ -

Final Contract Amount $ - Percent Changes $ -

Insert Name/Description of Project Here Comments:

Contract Award $ -

Changes $ - Final Contract Amount $ - Percent Changes $ -

Insert Name/Description of Project Here Comments:

Contract Award $ -

Changes $ - Final Contract Amount $ - Percent Changes $ -

BUDGET COMPLIANCE

696-FD-26-Q040 Page 4 of 6

INDIVIDUAL EXPERIENCE

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

Name Present Position Years of Typical $ Type of Work or Office Experience Amount Responsible for

EQUIPMENT

List the major equipment owned by the Firm:

696-FD-26-Q040 Page 5 of 6

Individual Project Bonding Company with mailing address and zip code Phone No.

Aggregate Bonding Company with mailing address and zip code Phone No.

References (Bank and Trade) with addresses and zip codes

APPROVAL

Name of Firm (Contractor)

Signature of Owner or Officer

Title of Person signing

CERTIFICATION

STATE OF )

COUNTY OF )

M being duly sworn deposes and says that he or she is the of

Title Contractor's Firm Name and that answers to the foregoing questions and all statements therein contained are true and correct.

Sworn to before me this day of

Notary Public in and for County, State My Commission expires

MAXIMUM BONDING CAPACITY:

696-FD-26-Q040 Page 6 of 6