2025-019_Qualification_Form.pdf

Chengwatana 530th St Field Invasives Management 1 of 2 Qualification Form Solicitation # 2025-019 8/7/24

Chengwatana 530th St Field Invasives Management

Solitication # 2025-019

PRIME CONTRACTOR RESPONSE

QUALIFICATION FORM

VERSION: Original

This Prime Contractor Response Qualification Form must be submitted with your solicitation response. A solicitation response received without this form, or with an outdated version, may be rejected. Prime Contractors are responsible for checking all addenda for the final version of this form.

Each responder must answer every question and provide all information requested on this form. Failure to meet this requirement may result in the rejection of the entire solicitation response as non-responsive.

The State (or its representative) reserves the right to clarify the required qualification information submitted on this form before an award is made. The solicitation response will be rejected if qualifications are not met.

Qualification Requirements

If the qualification requirements listed below are not met, either on the face of the submitted information or after such clarification/verification as the State may request, then the Contractor’s response may be rejected.

CHECK THE FOLLOWING THAT APPLY.

1. Requirement: Contractor must have a minimum of two (2) years’ experience in broadcast forest herbicide application, or roadside and rights-of-way application, using ground equipment.

I (Contractor) ____ “HAVE” ____ “DO NOT HAVE” a minimum of two (2) years’ experience in broadcast forest herbicide application, or roadside and rights-of-way application, using ground equipment.

2. Requirement: Contractor’s on-site herbicide applicator(s) must have minimum of one (1) year of experience in herbicide application, using ground equipment.

On-site applicator(s)____ “HAVE” ____ “DO NOT HAVE” a minimum of one (1) year experience in herbicide application, using ground equipment.

3. Requirement: Contractor and all on-site applicators must be able to accurately identify the target invasive plants stated in the specifications in their early summer growth stage.

Contractor and all on-site applicator(s)____ “DO” ____ “DO NOT HAVE” the ability to identify the target invasive plants (spotted knapweed) in their early summer growth state.

Continued on following page

Chengwatana 530th St Field Invasives Management 2 of 2 Qualification Form Solicitation # 2025-019 8/7/24

COMPLETE THE FOLLOWING FOR ALL HERIBICIDE APPLICATORS TO BE UTILIZED:

4. Requirement: Each applicator must have a license recognized by the Minnesota Department of Agriculture to commercially apply herbicides (MN Category A, plus G or J, or equivalent), and must have in possession a current card or license. Proof of licensure must be submitted with the bid.

NAME POSITION

YEARS OF

EXPERIENCE TYPE OF WORK

MN

LICENSE

CATEGORY

(S)

APPLICATOR

LICENSE NUMBER

5. Has your Company been found in default or had a contract terminated for cause in the last 36 months?

It is required that your company has not had this occur.

NOTE: If this question is answered as “yes”, your solicitation response will be rejected.

☐YES ☐NO

6. Has your Company received from OSHA any willful or repeated safety citations for which a final order has been issued within the last 36 months?

It is required that your company has not had this occur.

NOTE: If this question is answered as “yes”, your solicitation response will be rejected.

☐YES ☐NO

Certification

By signing this form, I certify the information provided above is complete and accurate.

Authorized Signature: _________ Date:

Printed Name: ______Telephone:

Company Name: Title: