21-00 Contractors Qualification.pdf

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E. CONTRACTOR’S QUALIFICATION STATEMENT

This statement is to be submitted as part of the Bid Package. (Note: Attach separate sheets if needed.)

The undersigned certified the truth and correctness of all statements and of all answers to questions made hereinafter.

Submitted by: Corporation

Name: Partnership

Address: Individual

Principal Office: Joint Venture

Other

How many years has your organization been in business as a Traffic Signal Contractor?

How many years has your organization been in business under its present business name?

If a corporation, answer the following:

1) Date of incorporation:

2) State of incorporation:

3) President’s name:

4) Vice President’s name(s):

5) Secretary or Clerk’s name:

6) Treasurer’s name:

7) List name and address of all parties holding greater than ten percent (10%) interest in the corporation:

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If individual or partnership, answer the following:

1) Date of origination:

2) Name and address of all partners (State whether general or limited partnership):

If other than corporation or partnership, describe organization and name principals:

We normally perform ____% of the work with our own employees. List trades below:

Have you ever failed to complete any work awarded to you? If so, note when, where and why:

Has any officer or partner of your organization ever been an officer or partner of another organization that failed to complete a construction contract? If so, state circumstances:

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List at least two other municipalities where your firm has performed preventive and response maintenance on both Siemens and Econolite control equipment to date and include a contact name and number at these municipalities:

List at least three additional municipalities where your firm has experience performing preventive and response maintenance that may not utilize Siemens and Econolite control equipment and include a contact name and number at these municipalities:

Describe your firm’s expertise related to maintaining and troubleshooting fiber optic and wireless Ethernet communications networks, including your familiarity and experience working on PennDOT’s Commonwealth network hubs, experience with layer 2 and layer 3 switches, and testing and tipping of fiber optic cable. If not capable in-house, name the subcontractors you use for these services and provide their answers to these questions.

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List the names of IMSA certified employees and their associated levels of traffic signal (and other) certifications.

Dated at this day of , 20 .

Name of Organization:

By:

Title:

M , being duly sworn, deposes and says that he/she is the of Contractor(s), and that answers to the foregoing questions and all statements therein contained are true and correct.

Subscribed and sworn before me this day of , 20 .

Notary Public:

My Commission Expires: