2-05 Required Forms.pdf

CONTRACTOR STATUS INFORMATION

Instructions: Please fill in the appropriate section below for the type of business entity through which Contractor operates, completing all blanks within the section. This information is necessary to ensure that the contract and bonds are in the correct form.

SECTION 1: If the contractor is a SOLE PROPRIETOR, fill in this section only:

Name:

First Middle Last

Name under which you are engaged in business (if operating under an assumed name):

Residence:

Street City County State ZIP

Business:

Street City County State ZIP

Principal place of business:

City County State ZIP

Contact Person:

Name Phone

SECTION 2: If the contractor is a PARTNERSHIP, fill in this section only:

Name of Partner:

First Middle Last

Residence:

Street City County State ZIP

Name of Partner:

First Middle Last

Residence:

Name under which contractor conducts business (if operating under an assumed name):

Business Address:

Principal place of business:

City County State Zip

Contact Person:

Name Phone

Texas Secretary of State Filing number: _____________________

SECTION 3: If the contractor is a CORPORATION, fill in this section only:

Registered name of corporation:

Doing business as:

Date charter expires:

State of corporation:

Date of corporation filing: (If non-Texas corporation, date of Certificate of Authority Issuance).

Texas Secretary of State Filing number: _____________________

Registered Agent:

First Middle Last

Address:

Location of Corporation principal office:

Person executing contract on behalf of corporation: (Please print)

Name:

First Middle Last

Title:

Address:

Street City County State ZIP

Telephone Number:

SECTION 4: If the contractor is a LIMITED PARTNERSHIP, fill in this section only:

Registered name of limited partnership:

Doing business as:

Date charter, if any, expires:

State of creation:

Date of registration or filing, if any: (If non-Texas corporation, date of Certificate of Authority Issuance).

Registered Agent:

First Middle Last

Address:

Location of limited partnership principal office:

Registered name of limited partnership’s general partner:

Doing business as:

Date charter, if any, expires:

State of corporation or creation:

Date of corporation filing, if any: (If non-Texas corporation, date of Certificate of Authority Issuance).

Texas Secretary of State Filing number: _____________________

Registered Agent:

Address:

Location of general partner’s principal office:

Person executing contract on behalf of general partner for limited partnership: (Please print)

Name:

Title:

Address:

Telephone Number:

OUT OF STATE CONTRACTOR COMPLIANCE TO STATE LAW

Texas Government Code § 2252.002 provides that, in order to be awarded a contract as low bidder, a non-resident bidder (out-of-state contractor whose corporate office or principal place of business is outside the State of Texas) bid projects in Texas at an amount lower than the lowest Texas resident bidder by the same amount that a Texas resident bidder would be required to underbid a non-resident bidder in order to obtain a comparable contract in the state in which the non-resident's principal place of business is located. The appropriate blanks in the following statement must be filled out by all out-of-state or non-resident bidders in order for those bids to meet specifications. (This information may be obtained from the Texas Register.) The failure of out-of-state or non-resident contractors to do so will automatically disqualify that bidder.

Non-resident contractor in ___________________ (give state), our principal place of business, is required to be _________ percent lower than resident bidders by State Law. A copy of the statute is attached.

Non-resident contractor in ___________________ (give state), our principal place of business, is not required to underbid resident bidders.

BIDDER

By Company (Please Print)

Address Signature

City State Zip Title (Please Print)

STATEMENT OF BIDDING CONTRACTOR’S QUALIFICATIONS AND EXPERIENCE

CONTRACTOR _____________________________________________________

Note: Demonstrate a minimum of three years’ experience. The information provided to the City on this form will be used, in part at least, to determine whether the perceived low bidder is the responsible low bidder for purposes of this Project.

PLEASE RESPOND TO THE FOLLOWING QUESTIONS:

1. Number of years in business as a General Contractor performing the type(s) of work required for this Project. ______________________________.

2. Types of work performed:

� Asphalt Paving � Concrete Structures � Miscellaneous Concrete

� Auxiliary Lanes � Demolition � Storm Sewer

� Bridge Work � Earth Work � Subgrade Preparation

� Channel Lining � Fencing � Other ____________

� Concrete Paving � Landscaping � _________________

3. Greatest number of contracts in excess of $500,000.00 under construction at one time in company’s history. ______________________________.

4. Greatest number of contracts in excess of $1,000,000.00 under construction at one time in company’s history. ______________________________.

5. Approximate average of dollar value of incomplete work outstanding under contacts at any one time. ______________________________.

6. List completed projects of the type of work of this Project or similar work plus the following information on each such project (use attachments for additional work if necessary).

NAME OF PROJECT: ____________________________________________________

OWNER: ______________________________________________________________

POINT OF CONTACT: ____________________________ PHONE: ________________

TOTAL CONTRACT COST: ______________COMPLETION DATE: ______________

DESCRIPTION: _________________________________________________________

Number Workdays Allowed: _________ Number Workdays Required: __________

Extra Days Granted: __________ Amount Liquidated Damages: _________________

POINT OF CONTACT: ____________________________ PHONE: ________________

TOTAL CONTRACT COST: ______________COMPLETION DATE: ______________

DESCRIPTION: _________________________________________________________

POINT OF CONTACT: ____________________________ PHONE: ________________

TOTAL CONTRACT COST: ______________COMPLETION DATE: ______________

DESCRIPTION: _________________________________________________________

POINT OF CONTACT: ____________________________ PHONE: ________________

TOTAL CONTRACT COST: ______________COMPLETION DATE: ______________

DESCRIPTION: _________________________________________________________

POINT OF CONTACT: ____________________________ PHONE: ________________

TOTAL CONTRACT COST: ______________COMPLETION DATE: ______________

DESCRIPTION: _________________________________________________________

7. List incomplete projects, plus the following information on each such project (use attachments for additional work if necessary).

POINT OF CONTACT: ____________________________ PHONE: ________________

CONTRACT COST: ___________ PROJECTED COMPLETION DATE: ___________

Number Workdays Allowed: _________ Number Workdays used to date: ________

Extra Days Granted: __________ Anticipated Late Days, if any: _________________

8. Have you or any present partner(s) or officer(s) failed to complete a contract? _____ If yes, please list the projects for which contracts were not completed, plus the following information on each such project (use attachments for additional work if necessary).

COMPANY NAME, if different: _____________________________________________

NAME OF PARTNER / OFFICER: __________________________________________

OWNER: ______________________________________________________________

POINT OF CONTACT: ____________________________ PHONE: ________________

CONTRACT COST: ___________ DEFAULT / TERMINATION DATE: ____________

DESCRIPTION: _________________________________________________________

SURETY: ______________________________________________________________

POINT OF CONTACT: ____________________________ PHONE: _______________

PERFORMANCE / PAYMENT BOND NUMBERS: ______________________________

NAME OF PARTNER / OFFICER: __________________________________________

OWNER: ______________________________________________________________

POINT OF CONTACT: ____________________________ PHONE: ________________

CONTRACT COST: ___________ DEFAULT / TERMINATION DATE: ____________

DESCRIPTION: _________________________________________________________

SURETY: ______________________________________________________________

NAME OF PARTNER / OFFICER: __________________________________________

CONTRACT COST: ___________ DEFAULT / TERMINATION DATE: ____________

SURETY: ______________________________________________________________

NAME OF PARTNER / OFFICER: __________________________________________

OWNER: ______________________________________________________________

POINT OF CONTACT: ____________________________ PHONE: ________________

CONTRACT COST: ___________ DEFAULT / TERMINATION DATE: ____________

DESCRIPTION: _________________________________________________________

SURETY: ______________________________________________________________

NAME OF PARTNER / OFFICER: __________________________________________

OWNER: ______________________________________________________________

POINT OF CONTACT: ____________________________ PHONE: ________________

CONTRACT COST: ___________ DEFAULT / TERMINATION DATE: ____________

DESCRIPTION: _________________________________________________________

SURETY: ______________________________________________________________

9. Are there any unsatisfied demands upon you regarding your accounts payable? If yes, give names, amounts and explanations (use attachments for additional unsatisfied demands if necessary). __________________________________________________

10. Have you or any present partner(s) or officer(s) been convicted of a felony or a crime involving moral turpitude (i.e., theft, bribery, fraud, perjury and so forth) within the past ten (10) years? _____ If yes, please list the date of each such conviction, the identity of the person(s) so convicted, the crime for which each such person was convicted, the sentence(s) issued for each such conviction, the current status of the sentence(s) and whether the conviction was related to any project(s) for which contracts were awarded by a governmental entity (use attachments for additional convictions if necessary).

11. Have you or any present partner(s) or officer(s) been debarred, or otherwise disqualified, from receiving or participating in federal contracts or federally approved subcontracts or from any type of federal financial or nonfinancial assistance or benefits? _____ If yes, please explain the facts surrounding such debarment in detail by identifying the project giving rise to debarment, the action date and termination date of debarment, and the cause(s) for debarment (use attachments for additional debarments if necessary). ________________________________________

12. Bank Reference.

NAME OF BANK: __________________________________________________________

BANK OFFICER: ___________________________________ PHONE: _________________

MAILING ADDRESS: __________________________________________________________

_________________________________________________ FAX: ___________________

NAME OF BANK: __________________________________________________________

BANK OFFICER: ___________________________________ PHONE: _________________

_________________________________________________ FAX: ___________________

13. Municipality References

NAME OF CITY: __________________________________________________________

CONTACT PERSON: ________________________________ TITLE: ___________________

PHONE: _________________ FAX: ___________________

PHONE: _________________ FAX: ___________________

PHONE: _________________ FAX: ___________________

14. Other credit references

NAME OF REFERENCE: _______________________________________________________

PHONE: _________________ FAX: ___________________

PHONE: _________________ FAX: ___________________

PHONE: _________________ FAX: ___________________

ACKNOWLEDGEMENT

(Use this form if the Contractor is a sole proprietorship)

THE STATE OF TEXAS §

COUNTY OF _____________ §

I certify that my responses and the information provided are true and correct to the best of my personal knowledge and belief and that I have made no willful misrepresentations in this Statement of Qualifications and Experience (“Statement”), nor have I withheld any relevant information in my statements and answers to questions. I am aware that any information given by me in this Statement may be investigated and I hereby give my full permission for any such investigation, and I fully acknowledge that any misrepresentations or omissions in my responses and information may cause my bid to be rejected.

a ____________ Sole Proprietorship, By: ______________________________ Name: ________________________

Date Signed: ____________________

This instrument was acknowledged before me on the ______ day of ________________, 20_____, by _______________________, in their capacity as owner of _________________, a ____________ sole proprietorship, known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that they executed the same for the purposes therein expressed.

GIVEN UNDER MY HAND AND SEAL OF OFFICE, THIS THE

DAY OF , 20_____.

Notary Public County, Texas My commission expires

(Use this form if the Contractor is an ordinary partnership.)

I certify that my responses and the information provided are true and correct to the best of my personal knowledge and belief and that I have made no willful misrepresentations in this Statement of Qualifications and Experience (“Statement”), nor have I withheld any relevant information in my statements and answers to questions. I am aware that any information given by me in this Statement may be investigated and I hereby give my full permission for any such a ____________ Partnership, By and through its Partner

20_____, by _______________________, in their capacity as a partner of _________________, a ____________ partnership, known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that they executed the same on behalf of and as the act of the partnership..

(Use this form if the Contractor is a corporation)

I certify that my responses and the information provided are true and correct to the best of my personal knowledge and belief and that I have made no willful misrepresentations in this Statement of Qualifications and Experience (“Statement”), nor have I withheld any relevant information in my statements and answers to questions. I am aware that any information given by me in this Statement may be investigated and I hereby give my full permission for any such a ____________ Corporation, Title: _________________________

20_____, by _______________________, in their capacity as _____________ of _________________, a ____________ Corporation, known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that they executed the same on behalf of and as the act of the corporation.

(Use this form if the Contractor is a limited partnership.)

I certify that my responses and the information provided are true and correct to the best of my personal knowledge and belief and that I have made no willful misrepresentations in this Statement of Qualifications and Experience (“Statement”), nor have I withheld any relevant information in my statements and answers to questions. I am aware that any information given by me in this Statement may be investigated and I hereby give my full permission for any such a ____________ Limited Partnership, By and through its General Partner a ____________________________, _________________, a ___________________, known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that ___________________, is the general partner of _______________________, a ____________ Limited Partnership, and that they executed the same on behalf of and as the act of the limited partnership.

STATEMENT OF SUBCONTRACTOR’S QUALIFICATIONS AND EXPERIENCE

SUBCONTRACTOR _____________________________________________________

Note: Demonstrate a minimum of three years’ experience for each subcontractor the Bidding Contractor intends to use on the Project (use attachments for additional subcontractors if necessary).

NAME OF PROJECT: __________________________________________________________

OWNER:

POINT OF CONTACT: ___________________________ PHONE: __________________

GENERAL CONTRACTOR:

POINT OF CONTACT: ___________________________ PHONE: __________________

TOTAL CONTRACT COST: ________________ COMPLETION DATE: ______________

DESCRIPTION: _______________________________________________________________

Number Workdays Allowed: _____________ Number Workdays Required: __________

Extra Days Granted: __________ Amount Liquidated Damages Assessed, if any: _________

NAME OF PROJECT: __________________________________________________________

OWNER:

POINT OF CONTACT: ___________________________ PHONE: __________________

GENERAL CONTRACTOR:

POINT OF CONTACT: ___________________________ PHONE: __________________

TOTAL CONTRACT COST: ________________ COMPLETION DATE: ______________

DESCRIPTION: _______________________________________________________________

NAME OF PROJECT: __________________________________________________________

OWNER:

POINT OF CONTACT: ___________________________ PHONE: __________________

GENERAL CONTRACTOR:

POINT OF CONTACT: ___________________________ PHONE:

TOTAL CONTRACT COST: ________________ COMPLETION DATE: ______________

DESCRIPTION: _______________________________________________________________

RECORD QUESTIONNAIRE & STATEMENT OF BIDDER’S SAFETY EXPERIENCE

Pursuant to Section 252.0435 of the Local Government Code, the McKinney City Council will consider the safety records of potential contractors prior to awarding bids on City contracts. The City of McKinney has adopted the following written definitions and criteria for accurately determining the safety record of a bidder prior to awarding bids on City contracts. The term “bidder” includes the firm, corporation, partnership, or other legal entity represented by the bidder or anyone acting for such firm, corporation, partnership or other entity submitting the bid. The definitions and criteria for determining the safety record of a bidder are:

“Citations” include notices of violation, notices of enforcement, suspension/revocations of state or federal licenses or registrations, fines assessed pending criminal complaints, indictments, or convictions, administrative orders, draft orders, final orders, and judicial final judgments. Notice of Violations and Notice of Enforcement received from the TCEQ shall include those classified as major violations and moderate violations under the TCEQ’S regulations for documentation of Compliance History, 30 Texas Administrative Code, Chapter 60.2 (c) (1) and (2).

“Environmental Protection Agency” includes, but is not limited to the Texas Commission on Environmental Quality (TCEQ), the U.S. Environmental Protection Agency (EPA), the U.S. Fish and Wildlife Service, the U.S. Army Corps of Engineers, the Texas Department of Health, the Texas Parks and Wildlife Department, the Structural Pest Control Service, agencies of local governments responsible for enforcing environmental protection laws or regulations, and similar regulatory agencies of other states of the United States.

1. If the Bidder’s response to the following questions reveals more than two (2) cases in which final orders have been entered by the Occupational Safety and Health Review Commission (OSHRC) against the bidder for serious violations of Occupational Safety & Health Administration (OSHA) regulations within the past five (5) years, the City will, at its discretion, determine whether to disqualify the bidder.

2. If the Bidder’s response to the following questions reveals more than one (1) case in which

Bidder has received a Citation or for which final orders have been entered from an environmental protection agency for violations within the past five (5) years, the City will, at its discretion, determine whether to disqualify the bidder.

3. If the Bidder’s response to the following questions reveals that the Bidder has been convicted of a criminal offense within the past ten (10) years or has been subject to a judgment for a negligent act or omission, which resulted in serious bodily harm or death, at its discretion, the City will determine whether to disqualify the bidder.

4. The City may consider the responses to each question listed below separately when making a discretionary determination of whether to disqualify a Bidder and it may consider the cumulative impact of the information generated by the Bidder’s responses in making the determination.

5. In order to consider the safety records of potential contractors prior to awarding bids on

City contracts, the City requires that Bidders answer the following four (4) questions and submit them with their bids:

QUESTION ONE

Has the “Bidder” received any Citations for violations of OSHA within the past five (5) years? � Yes � No

QUESTION TWO

Has the Bidder received any Citations for violations of environmental protection laws or regulations within the past five (5) years? � Yes � No

QUESTION THREE

Has the Bidder ever been convicted, within the past ten (10) years of a criminal offense which resulted in or gave rise to serious bodily injury or death? � Yes � No

QUESTION FOUR

Has the Bidder ever been sued, within the past ten (10) years, for a negligent or wrongful intentional act or omission arising out of or in conjunction with a project on which the Bidder worked that resulted in or gave rise to serious bodily injury or death? � Yes � No

If the Bidder has indicated "Yes" to Questions 1, 2 and/or 3 above, the Bidder must provide to the City, with its bid submission, the following information:

(a) Date of Citation or offense and location where violation or offense occurred;

(b) Type of violation or offense;

(c) Final disposition of violation or offense, if any; and,

(d) Penalty assessed.

If the Bidder has indicated "Yes" to Question 4 above, the Bidder must provide to the City, with its bid submission, the following information:

(a) Date of negligent or wrongful intentional act or omission and location where such act or omission occurred;

(b) Type of negligent or wrongful intentional act or omission asserted;

(c) Whether gross negligence was asserted;

(d) Whether a finding of gross negligence was made;

(e) Final disposition of litigation, if any; and,

(f) Amount of judgment awarded.

In addition, the City will utilize the following information and, in its discretion, as additional support to make any discretionary determination of whether to disqualify a Bidder. Accordingly, Bidder must answer the following questions and provide evidence that it meets minimum OSHA construction safety standards and has a lost time injury rate that does not exceed the limits established below:

1. Does the Bidder have a written construction safety program? � Yes � No

2. Does the Bidder conduct regular construction site safety inspections? � Yes � No

3. Does the Bidder have an active construction safety training program? � Yes � No

4. Has the Bidder been fined by OSHA for any willful safety violations in the past three (3) years? � Yes � No

5. Does the Bidder have a lost time injury rate and a total recordable injury rate of less than or equal to the national average for North American Industrial Classification System (NAICS) Category 23 for each of the past five (5) years? (Attach the Bidder's OSHA 300/300A logs for the past five (5) years) � Yes � No

6. Does the Bidder have an experience modifier rate of 1.0 or less? (Attach the

Bidder's NCCI workers compensation experience rating sheets for the past five (5) years) � Yes � No

7. Does the Bidder or affected subcontractors have competent persons in the following areas (as applicable to the scope of the current Project):

A. Scaffolding � Yes � No � N/A B. Excavation � Yes � No � N/A C. Cranes & Hoists � Yes � No � N/A D. Electrical � Yes � No � N/A E. Fall Protection � Yes � No � N/A F. Confined Spaces � Yes � No � N/A G. Material Handling � Yes � No � N/A H. Demolition � Yes � No � N/A I. Steel Erection � Yes � No � N/A J. Underground Construction � Yes � No � N/A

8. Has the “Bidder” had any OSHA inspections within the past six (6) months for which no Citations have been received or for which any Citations have been resolved or vacated? � Yes � No

If the Bidder has indicated “YES” to questions 4, 5, 6, or 8 above, the Bidder must provide to the City, with its bid submission, sufficient supporting documentation to indicate the nature and magnitude of the underlying issues.

(Use this form if the Contractor is a sole proprietorship)

I certify that my responses and the information provided are true and correct to the best of my personal knowledge and belief and that I have made no willful misrepresentations in this Questionnaire, nor have I withheld any relevant information in my statements and answers to questions. I am aware that any information given by me in this questionnaire may be investigated and I hereby give my full permission for any such investigation, and I fully acknowledge that any misrepresentations or omissions in my responses and information may cause my bid to be rejected.

a ____________ Sole Proprietorship, 20_____, by _______________________, in their capacity as owner of _________________, a ____________ sole proprietorship, known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that they executed the same for the purposes therein expressed.

(Use this form if the Contractor is an ordinary partnership.)

I certify that my responses and the information provided are true and correct to the best of my personal knowledge and belief and that I have made no willful misrepresentations in this Questionnaire, nor have I withheld any relevant information in my statements and answers to questions. I am aware that any information given by me in this questionnaire may be investigated and I hereby give my full permission for any such investigation, and I fully acknowledge that any a ____________ Partnership, By and through its Partner

20_____, by _______________________, in their capacity as a partner of _________________, a ____________ partnership, known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that they executed the same on behalf of and as the act of the partnership..

(Use this form if the Contractor is a corporation)

I certify that my responses and the information provided are true and correct to the best of my personal knowledge and belief and that I have made no willful misrepresentations in this Questionnaire, nor have I withheld any relevant information in my statements and answers to questions. I am aware that any information given by me in this questionnaire may be investigated and I hereby give my full permission for any such investigation, and I fully acknowledge that any a ____________ Corporation, _________________, a ____________ Corporation, known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that they executed the same on behalf of and as the act of the corporation.

(Use this form if the Contractor is a limited partnership.)

I certify that my responses and the information provided are true and correct to the best of my personal knowledge and belief and that I have made no willful misrepresentations in this Questionnaire, nor have I withheld any relevant information in my statements and answers to questions. I am aware that any information given by me in this questionnaire may be investigated and I hereby give my full permission for any such investigation, and I fully acknowledge that any a ____________ Limited Partnership, By and through its General Partner a ____________________________, _________________, a ___________________, known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that ___________________, is the general partner of _______________________, a ____________ Limited Partnership, and that they executed the same on behalf of and as the act of the limited partnership.