3-03- Statement of Qualification Form (1).pdf

STATEMENT OF QUALIFICATIONS FORM

1. FIRM NAME:

2. BUSINESS ADDRESS OF RESPONDENTS HEADQUARTERS:

3. TELEPHONE, WITH AREA CODE:

FAX, WITH AREA CODE:

EMAIL ADDRESS( :

INTERNET URL ADDRESS:

4. TYPE OF ORGANIZATION: (CHECK ONE)

a. SOLE PROPRIETORSHIP ( )

b. PARTNERSHIP ( )

c. CORPORATION ( )

d. JOINT VENTURE ( )

5. PRINCIPALS (P) AND ASSOCIATES (A):

(WRITE “P” OR “A” FOR EACH)

DEGREE OR

NAME P/A CERTIFICATE INSTITUTION

a. _________________________ ___ ______________ _______________

b. _________________________ ___ ______________ _______________

c. _________________________ ___ ______________ _______________

6. LIST FIVE MAJOR ENGAGEMENTS WITHIN THE PAST THREE YEARS THAT ILLUSTRATE

YOUR EXPERIENCE WITH SIMILAR ENGAGEMENTS.

ENGAGEMENT/ YEAR

SERVICES

PROVIDED

PROJECT MGR.

NAME

CLIENT CONTACT

NAME AND

PHONE NO.

a.

b.

c.

d.

c.

7. REFERENCES:

(INCLUDE AT LEAST THREE REFERENCES FROM THREE SIMILAR ENGAGEMENTS). LIMIT

CITY OF LUBBOCK REFERENCES TO ONE IF POSSIBLE.

NAME RELATIONSHIP PHONE NUMBER

a. _____________________ ________________________ __________________

b. _____________________ ________________________ __________________

c. _____________________ ________________________ __________________

d. _____________________ ________________________ __________________

e. _____________________ ________________________ __________________

8. PRESENT WORKLOAD:

PROVIDE NAMES/TITLE AND PRESENT WORKLOAD OF THE PROJECT TEAM

NAME /TITLE PROJECT

PROJECT

COMPELETION DATE

SUBMITTED BY:

Signature: Date:

Printed Name: Title:

Firm Name: Tel:

Address: State: Zip:

PRIVACY NOTIFICATION

The principal purpose for requesting the above information is for use in the selection process for professionals commissioned by the City of Lubbock.

Furnishing all information requested on the form is mandatory. Failure to provide such information will delay or may even prevent completion of the action for which the form is being completed. Information on the form is used by the City of Lubbock and its Management Team in the consideration of commissions to professionals.

If you consider any portion of your submittal to be privileged or confidential by statute or judicial decision, including trade secrets and commercial or financial information, clearly identify those portions.

Submittals are opened in a manner that avoids disclosure of the contents to competing offerors and keeps the submittals secret during negotiations. All submittals are open for public inspection after the contract is awarded, but trade secrets and confidential information in the submittals are not open for inspection.

The City of Lubbock will honor your notations of trade secrets and confidential information and decline to release such information initially, but please note that the final determination of whether a particular portion of your submittal is in fact a trade secret or commercial or financial information that may be withheld from public inspection will be made by the Texas Attorney General or a court of competent jurisdiction. In the event a public information request is received for a portion of your submittal that you have marked as being confidential information, you will be notified of such request and you will be required to justify your legal position in writing to the Texas Attorney General pursuant to Section 552.305 of the Government Code. In the event that it is determined by opinion or order of the Texas Attorney General or a court of competent jurisdiction that such information is in fact not privileged and confidential under Section 552.110 of the Government Code and Section

252.049 of the Local Government Code, then such information will be made available to the requester.

Marking your entire submittal CONFIDENTIAL/PROPRIETARY is not in conformance with the Texas Open Records Act.