26-SWU06 FORM C.PDF

This form must be returned with your response.

COMPANY INFORMATION

Company Name (Make sure to use your complete, legal company name.)

FEIN (If FEIN is not applicable, SSN collected upon award.)

Contact Name (Able to answer questions about proposal.) Title

Telephone Number Fax Number

Email

Address City State Zip

ORDERS/BILLING CONTACT

Address where City purchase orders/contracts are to be mailed and person the department contacts concerning orders and billing.

Contact Title

Telephone Number Fax Number

Email

Address City State Zip

LOCAL VENDOR STATUS

Form C: Vendor Profile/Qualifications

RFQ#: 26-SWU08

The City of Sun Prairie has included a local vendor preference granting a scoring preference to local suppliers. Only suppliers within the City of Sun Prairie limits as of the bid’s due date will receive preference.

CHECK ONLY ONE:

Yes, we are a local vendor.

No, we are not a local vendor.

CORPORATION INFORMATION

If applicant is a corporation, please complete both columns:

Names of Corporate Officers Names of Corporate Directors

LICENSES AND PROFESSIONAL REGISTRATION

List names of each key person of the firm. If a requested service requires a licensed/registered practitioner, you will be required to provide a copy of such license/registration before work can begin.

Name Capacity

(Owner, Partner, Etc.)

Current Licenses/Registrations (Include Certificate # if applicable)

License/Registration Expiration Date

CONFLICT OF INTEREST

A conflict of interest may exist where an employee or close relative/family member has a connection to your business, and a third party may consider that this relationship may compromise the competitive process. Does any employee of your company have a possible conflict of interest with this process? Yes No If yes, please specify the following:

Employee Name: __________________________ Employee Phone Number: _______________

Employee’s Relationship: _________________________

PRIOR WORK

Has your organization ever performed work for the City of Sun Prairie? Yes No If yes, please specify scope of work:

WORK EXPERIENCE

List contracts for similar services or materials that have been completed within the last five years.

Project Location Type of Service Total Amount of Contract

Completion Date

Name/Phone of Owner or Other

References

KEY PROJECT PERSONNEL INFORMATION

Provide the requested information for key personnel who would be assigned to work on contracts awarded or who would, at a minimum, supervise such work.

Name and Title Primary Responsibilities

Years of Experience

Education (Degrees, Certificates)

Other Relevant Experience and/or

Qualifications

JUDGEMENTS AND CLAIMS

Are there any judgements, claims or suits pending our outstanding against you or your organization?

Yes No

If yes, please explain:

DISPUTES REGARDING LIENS

Has any owner or higher-tier contractor with whom you r business has had a contract ever disputed a claim of lien filed by you or your organization? Yes No

If yes, please explain:

RECEIVERSHIP

Have you or your organization filed for bankruptcy, receivership, or reorganization within the last five years?

Yes No

If yes, please explain:

LEGAL INFRACTIONS

Have you or your organization been cited and/or fined for failure to comply with federal or state regulations and/or statues in the past two years? Yes No

If yes, please explain:

Information provided in this application may be audited by the City of Sun Prairie.

Provision of information on Form C does not relieve your company from providing the same or additional information as requested in a response to a request for proposal.

Submittal of Form C does not guarantee qualification. Qualification will be given only if your company meets all statutory, regulatory or City requirements, including those not listed on this application. Qualification does not guarantee your company any business.

Your company must update significant information changes in writing within 30 days.

Significant changes include, but are not limited to: change of legal status, TIN, ownership, name, address, as well as loss of licensure or registration, filing of bankruptcy, or suspension by any federal, state, or local government agency.

Failure to provide accurate and reliable information required by this form may, in accordance with any and all applicable laws, result in penalties including, but not limited to, suspension or debarment from doing business with the City of Sun Prairie and termination of contracts.

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