3-Profile of Firm Form Comp Bio Fillable.pdf

PROFILE OF FIRM FORM (Page 1 of 2)

Prime Joint Venture/Partner Sub-Contractor (This form shall be completed by and for each).

Legal Name of Firm:

DBA (if applicable):

Telephone: Fax:

Street Address, City, State, Zip:

Certification Agency:

Federal Tax ID Number:

City of San Antonio Business License No.:

State of Texas License Type and No.:

Name Tit le % of Ownership

Is the business 51% or more owned by a public housing resident? Yes No

City:

Asian/Pacific American

Asian/Indian American

Caucasian American (Male)

Hasidic Jew

Other (Specify):

Hispanic American

Disabled Veteran

Identify principals/partners in firm:

Indicate the operating structure of the firm:

Publicly Held Corporation

Privately Held Corporation

Government Agency

Non-Profit Organization Partnership

Sole Proprietorship

Proposer's Diversity Statement

You must check all of the following that apply to the ownership of this firm and enter where provided the correct percentage (%) of ownership of each.

Minority (MBE) or Woman-Owned (WBE) Business Enterprises qualify by virtue of 51% or more ownership and active management by one or more of the following:

African American

Native American

Woman- Owned (MBE)

Woman-Owned (Caucasian)

If yes, provide name and address of the public housing facility:

Facility Name:

Facility Address:

(NOTE: A CERTIFICATION NUMBER IS NOT REQUIRED. ENTER IF AVAILABLE.)

SWMBE Certification Number:

PROFILE OF FIRM FORM (Page 2 of 2)

Debarred Statement: Has this firm, or any principal(s) ever been debarred from providing any services by the Federal Government, any state government, the State of Texas, or any local government agency within or without the State of Texas?

Yes No

If "Yes," please attach a full detailed explanation, including dates, circumstances and current status.

Disclosure Statement: Does this firm or any principals thereof have any current, past personal or professional relationship with any Commissioner or Officer of SAHA? Yes No

If "Yes," please attach a full detailed explanation, including dates, circumstances and current status.

Date

Has your firm or any member of your firm been a party to litigation with a public entity? If yes, when, with whom and state the circumstances and any resolution.

Has your firm or any member of your firm ever had a claim brought against because of breach of contract or non-performance?

If yes, when and state the circumstances and any resolution of the matter.

Has your firm or any member of your firm ever sued or been sued by the San Antonio Housing Authority or its affiliated entities?

If yes, when and state the circumstances and any resolution of the lawsuit.

Verification Statement: The undersigned Offeror hereby states that by completing and submitting this form he/she is verifying that all information provided herein is, to the best of his/her knowledge, true and accurate, and agrees that if the SAHA discovers that any information entered herein is false, that shall entitle the SAHA to not consider nor make award or to cancel any award with the undersigned party.

In performing this contract, the contractor(s) shall comply with any and all applicable federal, state or local laws including but not limited to: Occupational Safety & Health, Equal Employment Opportunity, Immigration and Naturalization, The Americans with Disabilities Act, State Tax and Insurance Law, and the Fair Housing Act.

Non-Collusive Affidavit: The undersigned party submitting this proposal hereby certifies that such proposal is genuine and not collusive and that said Offeror has not colluded, conspired, connived or agreed, directly or indirectly, with any Offeror or person, to put in a sham proposal or to refrain from proposing, and has not in any manner, directly or indirectly sought by agreement or collusion, or communication or conference, with any person, to fix the proposal price of affiant or of any other Offeror, to fix overhead, profit or cost element of said proposal price, or that of any other Offeror or to secure any advantage against the SAHA or any person interested in the proposed contract; and that all statements in said proposal are true.

Company

Initials

Initials

Initials

Initials

Initials

Signature Printed Name

Respondent Biography

Company Name:

Headquarters Location:

Field Office Location(s):

Business Specialty or Focus:

Number of Full Time Staff:

Founding Date and Brief History:

Texas Projects and/or Clients (Past and Current):

Previous Housing Authority Experience: YES NO

List the Authorities: