2-Attachment C - Statement of Offeror Qualifications.pdf

Attachment C

STATEMENT OF OFFEROR QUALIFICATIONS

This Statement of Offeror Qualifications requests information about Offeror that will be used in the evaluation of Offeror responsibility. All Offerors must complete this form in its entirety and submit with the submission of Qualifications. Answers should be as thorough and definitive as possible and include all pertinent data. Failure to fully and truthfully disclose the information required may result in the disqualification of your Qualifications from consideration or termination of the contract, once awarded. Supplemental materials, additional pages, or requested lists providing additional information may be attached to further clarify answers.

General Information

1. Name of company/organization: _______________________________________________

2. Address of company/organization:

3. Home office address (if other than above):

4. Telephone No: Fax No.:

5. Type of business entity (corporation, partnership, sole proprietorship, etc.):

A. If your organization is a corporation, please provide on a separate sheet(s), detailing the following: Date of incorporation, State of incorporation, Names of President, Vice-president, Secretary, and Treasurer.

B. If your organization is a partnership or individually owned, please attach a list detailing the following: Date of organization, Name of owner(s) or partners.

6. Place of incorporation (if applicable):

7. Type of work performed by your company:

8. Year founded/established:

9. Has your organization been in business under its present name for at least five (5) years? ☐ YES ☐ NO

A. If not, please explain why.

10. Primary individual to contact:

Litigation Record

Have you or any member of your organization or team brought any claim, litigation, or arbitration against Harris County or any other Federal, State or Local Government during the last five (5) years?

☐ YES ☐ NO

If yes, attach a list of any claims, lawsuits, or requested arbitrations and their final outcome.

Has Harris County or any other Federal, State or Local brought any claim or litigation against you or any member of your organization or team during the last five (5) years?

☐ YES ☐ NO

If yes, attach a list of any claims, lawsuits, or requested arbitrations and their final outcome.

Has you or any member of your organization or team filed any lawsuits or requested arbitration with regards to any contracts within the last five (5) years?

☐ YES ☐ NO

If yes, attach a list of any lawsuits or requested arbitrations and their final outcome.

Are there any administrative proceedings, claims, lawsuits, or other exposures pending against you or any member of your organization or team?

☐ YES ☐ NO

If yes, explain:

Have any subcontractors, in which your organization has some ownership, filed any lawsuits or requested arbitration with regards to any contracts within the last five (5) years?

☐ YES ☐ NO

If yes, explain:

Have you or any member of your organization or team to be assigned to this engagement been terminated (for cause or otherwise) from any work being performed for Harris County or any other Federal, State or Local Government, or Private Entity?

☐ YES ☐ NO

If yes, explain:

Have you ever failed to complete any work awarded to you? ☐ YES ☐ NO

If yes, explain, indicating what was not completed and the reasoning:

Have you ever defaulted on a contract? ☐ YES ☐ NO

If yes, explain:

Experience Record

How many years has your organization been providing the services identified in this RFQ to the following types of entities?

Government (Public) Entities: ____________

Private (Commercial) Entities: ____________

List three to five (3-5) similar projects as the one specified in this solicitation that your organization has completed over the last five (5) years. Attach additional pages as necessary:

1. _____________________________________________________________________________________________________________

2. _____________________________________________________________________________________________________________

3. _____________________________________________________________________________________________________________

4. _____________________________________________________________________________________________________________

5. _____________________________________________________________________________________________________________

Describe your organization’s concepts for working in a team relationship with the owner and user groups during the completion of projects similar to that identified in this RFQ. Identify which of the project(s) listed on Attachment E, References, best exemplify these concepts and experiences. Attach additional pages as necessary:

Please list categories of work that your organization normally performs with its own forces.

Please list subcontractors/subconsultants in which your organization has some ownership or relationship and list the categories of work those subcontractors/subconsultants normally perform.

1. _____________________________________________________________________________________________________________

2. _____________________________________________________________________________________________________________

3. _____________________________________________________________________________________________________________

4. _____________________________________________________________________________________________________________

Portions of work Offeror proposes to sublet in case of award of contract, including amount and type:

1. ______________________________________________________________________________________________________________

2. ______________________________________________________________________________________________________________

3. ______________________________________________________________________________________________________________

Dated this day _________ of _______________ 20___

(Name of Organization)

By:_______________________________________ (Title)

Submitted by______________________________ an individual a partnership a corporation with principal office at ________________________________________________________ (Full Address or City, State)

To be filled in by Corporation: To be filled in by Partnership Date incorporated _____________ Date formed ________________ Under the laws of _____________State. State whether partnership is general, limited or associated

Executive Officer ___________________ List Members:

State of ___________________

County of _________________

_________________________________________, being duly sworn, deposes and attests that he/she is (Name of Offeror’s Representative)

____________________________________ of ____________________________________________, (Position Title) (Name of Organization) and that: (1) the Offeror submitting a Statement of Qualifications for this contract opportunity and the contractors / subcontractors anticipated to perform the work are properly licensed, as applicable, and shall provide proof of said licensure needed to complete the scope of work; (2) the answers to the foregoing questions on the attached/associated forms and all statements therein are correct to the best of their knowledge; (3) the experience record are made part of this affidavit as though written in full herein; and (4) all statements and answers to the questions given in the above-mentioned experience record are true and correct.

_______________________________________________________, sworn to before me this _____ day (Name of Offeror’s Representative) of ______________, 20__.

____________________________ (Seal) Notary Public My Commission expires