N- GSA527 Contractor Qualifications.doc short version.rtf

CONTRACTOR'S QUALIFICATIONS AND FINANCIAL INFORMATION

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SECTION I - GENERAL INFORMATION

1A. NAME

2. TYPE OF ORGANIZATION (Check one)

A. SOLE PROPRIETORSHIP

F. LIMITED LIABILITY COMPANY

1B. STREET ADDRESS

B. GENERAL PARTNERSHIP

G. JOINT VENTURE

C. LIMITED PARTNERSHIP

H. TRUST

1C. CITY

1D. STATE

1E. ZIP CODE

D. CORPORATION

I. OTHER (Specify below)

E. SUBCHAPTER S CORPORATION

3. TAXPAYER ID NUMBER

4. DATE ORGANIZATION ESTABLISHED

5. STATE OF INCORPORATION

6. TRADE STYLE NAME (Provide a copy of filing)

7. KIND OF PRODUCT OR SERVICE PROVIDED

8. FORMER BUSINESS NAME

10. INVENTORY VALUATION METHOD

A. LIFO

C. AVERAGE COST

9. KIND OF BUSINESS

A. MANUFACTURER

D. RETAILER

B. FIFO

D. OTHER (Specify)

B. CONTRACTOR

E. OTHER (Specify)

C. WHOLESALER

11. OWNERSHIP INFORMATION-PARTNERS-PRINCIPAL STOCKHOLDERS-OTHERS

NAME

TITLE

(If partner, state G(General) or L(Limited) in column)

PERCENT BUSINESS OWNED

ACTUAL TITLE

G OR L

12. PARENT COMPANY (If applicable)

13. IF "YES" TO ANY QUESTION BELOW, PROVIDE DETAILED INFORMATION IN SECTION VIII, REMARKS

YES

NO

A. HAVE YOU, OR ANY OF YOUR AFFILIATES EVER FILED FOR BANKRUPTCY?

A. NAME

B. DO YOU HAVE ANY JUDGMENTS, LIENS, OR PENDING SUITS?

B. CITY

C. STATE

C. DO YOU HAVE ANY CONTINGENT LIABILITIES?

D. HAVE YOU OR ANY OF YOUR AFFILIATES DISCONTINUED BUSINESS

OPERATIONS WITH OUTSTANDING DEBTS?

SECTION II - GOVERNMENT FINANCIAL AID AND INDEBTEDNESS

14A. ARE YOU DELINQUENT ON ANY FEDERAL DEBT (OMB CIRCULAR A-129)

(If "Yes", provide detailed information, Section VIII, Remarks)

YES NO

14B. DO YOU OWE THE GOVERNMENT FOR ANY CONTRACT OR OTHER CLAIMS?

YES NO

IF "YES", COMPLETE THE ITEMS BELOW

AGENCY

CLAIM AMOUNT

PAYMENT

MATURITY

BALANCE

15A. AGENCY INVOLVED WITH DELINQUENCY

15B. AMOUNT OF DELINQUENCY ($)

16. ARE YOU CURRENTLY RECEIVING GOVERNMENT FINANCING?

YES

NO (Go to Section III )

17. COMPLETE ITEMS BELOW IF APPLICABLE

TYPE OF FINANCING

AUTHORIZED ($)

IN USE ($)

GOVERNMENT AGENCY INVOLVED

A. INDUSTRIAL REVENUE BONDS

B. GUARANTEED LOANS

C. ADVANCED PAYMENTS

D. PROGRESS PAYMENTS

E. OTHER (Specify)

LARGEST JOBS YOU HAVE COMPLETED IN THE LAST FIVE YEARS

56. JOB 1

57. JOB 2

A. Location

B. Contact's Name

C. Address

STREET ADDRESS

STREET ADDRESS

CITY

STATE

ZIP CODE

CITY

STATE

ZIP CODE

D. Telephone

AREA CODE

NUMBER

EXTENSION

AREA CODE

NUMBER

EXTENSION

E. Type of Work

F. Contract Amount ($)

G. Amount Sublet ($)

ITEM

58. JOB 3

59. JOB 4

A. Location

B. Contact's Name

C. Address

STREET ADDRESS

STREET ADDRESS

CITY

STATE

ZIP CODE

CITY

STATE

ZIP CODE

D. Telephone

AREA CODE

NUMBER

EXTENSION

AREA CODE

NUMBER

EXTENSION

E. Type of Work

F. Contract Amount ($)

G. Amount Sublet ($)

SECTION VIII - REMARKS

REMARKS (Cite those sections of the form relating to your remarks. If additional space is required, attach additional sheet(s).)

CERTIFICATION

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For the purpose of establishing financial responsibility with, or procuring credit from the U.S. General Services Administration, we furnish the above as a true and correct statement of our financial condition and further certify that all other statements are true and correct. There has been no material change in the applicant's financial condition since the date of the above statement. We agree to notify you immediately in writing of any materially unfavorable change in our financial condition. In the absence of such notice or of a new and full financial statement, this is to be considered as a continuing statement.

NAME OF BUSINESS

BY (Signature of Authorized Official)

NAME OF AUTHORIZED OFFICIAL (Type or print)

DATE

TITLE OF AUTHORIZED OFFICIAL (Type or print)