3-Profile of Firm Form REV 5.25.pdf

Profile of Firm

Prime Joint Venture/Partner Subcontractor

This form shall be completed by and for each

Legal Name of Firm

DBA

(If Applicable)

Telephone Fax

Address City, State, Zip

Contact Email

Accounts Payable Email (If different from above)

Purchase Order Email (If different from Contact Email)

Identify Principals/Partners in Firm

Name Title % of Ownership

Indicate the operating structure of the firm:

Publicly Held Corporation

Privately Held Corporation

Government Agency

Non-Profit Organization

Partnership

Sole

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:

Check all that apply Percentage (%)

African American

Native American

Hispanic American

Asian/Pacific American

Hasidic Jew

Asian/Indian American

Woman-Owned (MBE)

Woman-Owned (Caucasian)

Disabled Veteran

Caucasian American (Male)

Other (Specify)

Choose not to disclose

SWMBE Certification (Note: A certification number is not required, but if applicable please provide a copy)

Yes No

Certification Agency Name

Federal Tax ID Number

City of San Antonio Business License Number

State of Texas License Type and Number

Is the business 51% or more owned by a public housing resident?

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

Facility Name

Facility Address

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 sued or been sued by Opportunity Home San Antonio or its affiliated entities?

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

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.

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?

(If yes, please attach a full detailed explanation, with dates, circumstances and current status)

Initials

Disclosure Statement

Does this firm or any principals thereof have any current, past personal or professional relationship with any Commissioner or Officer of Opportunity Home? (If yes, please attach a full detailed explanation with dates, circumstances and current status)

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 Opportunity Home or any person interested in the proposed contract; and that all statements in said proposal are true.

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 Opportunity Home discovers that any information entered herein is false, that shall entitle Opportunity Home to not consider nor make award or to cancel any award with the undersigned party.

Verification Statement

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.

Printed Name

Company

Signature Date