4-Att C PROFILE OF PROPOSER.pdf

ATTACHMENT C

“PROFILE OF PROPOSER”

(This Form must be fully completed and placed under Part No.3 of the proposal submittal.)

(1) Prime ☐ Subcontractor ☐ (this form must be completed by and for each)

(2) Name of Proposer: __ Telephone: Fax: _____ E-Mail: _______________________ ___________

(3) Street Address, City, State, Zip:

(4) Please attach a brief biography/resume of the company, including the following information:

Year Proposer Established; (b) Former Name and Year Established (if applicable); and

(c) Name of Parent Company and Date Acquired (if applicable).

(5) Identify Principals/Partners in Proposer (submit under Part 5 a brief professional resume for each):

NAME TITLE % OF OWNERSHIP

(6) Identify the individual(s) that will act as project manager and any other supervisory personnel that will work on project; please submit under Part 5 a brief resume for each. (Do not duplicate any resumes required above):

NAME TITLE

(7) Federal Tax ID No.:

(8) State of California Business Entity Number (Secretary of State):

(9) Worker’s Compensation Insurance Carrier:

Policy No.: ___________________________________ Expiration Date:

(10) General Liability Insurance Carrier: ____________________________________________

Policy No.: ___________________________________ Expiration Date:

(11) Professional Liability Insurance Carrier:

[RFPNUMBER] [AHA, ICD, AAHC] [SERVICES] ISSUED: [ISSUED DATE]

Policy No.: ___________________________________ Expiration Date:

(12) Has your proposer or any member of your proposer been a part to litigation with a public entity?

☐ Yes ☐ No

If yes, please include in section a full detailed explanation including dates, with who and state the circumstances and any resolution.

(13) Is your proposer currently involved in local, County, State, Federal mortgage foreclosure proceedings or currently

90 days in arrears on a local public or private loan?

☐ Yes ☐ No

If yes, please include clarifying information including dates, with who and state the circumstances and any resolution in section (23) below.

(14) Is your proposer currently in foreclosure or substantial tax arrears with a City/County or local jurisdiction?

☐ Yes ☐ No

If yes, please include clarifying information including dates, with who and state the circumstances and any resolution in section (23) below.

(15) Has, or is this proposer or any member of your proposer, currently in default on any contract obligation or agreement of any kind entered into with a City/County or local public agency?

☐ Yes ☐ No

If yes, please include clarifying information including dates, with who and state the circumstances and any resolution in section (23) below.

(16) In the past 10 years, has your proposer or any member of your proposer failed to qualify as a responsible bidder, or refused to enter into a contract after an award has been made, privately or with any government agency?

☐ Yes ☐ No

If yes, please include clarifying information including dates, with who and state the circumstances and any resolution in section (23) below.

(17) In the last 7 years, has your proposer filed a bankruptcy petition or been the subject of involuntary bankruptcy proceedings?

☐ Yes ☐ No

If yes, please include clarifying information including dates, with who and state the circumstances and any resolution in section (23) below.

(18) In the last 10 years, failed to file any required tax returns, or failed to pay any applicable Federal, State of

California, or City of Alameda or other fees?

☐ Yes ☐ No

If yes, please include clarifying information including dates, with who and state the circumstances and any

(19) Does your proposer or any member of your proposer have a record of substantial Building Code Violations or litigation against properties owned by the proposer or by any entity or individual that comprises the Proposer?

☐ Yes ☐ No

If yes, please include clarifying information including dates, with who and state the circumstances and any

(20) Has your proposer or any member of your proposer been convicted for fraud, bribery, or grand larceny?

☐ Yes ☐ No

If yes, please include clarifying information including dates, with who and state the circumstances and any resolution in section (23) below.

(21) Debarred Statement: Has this proposer, or any principal(s) ever been debarred from providing any services by the Federal Government, any state government, the State of California, or any local government agency within or without the State of California? Has this proposer been de-designated as a developer of any government sponsored or publicly assisted project?

☐ Yes ☐ No

If yes, please include clarifying information including dates, with who and state the circumstances and any resolution in section (23) below.

(22) Disclosure Statement: Does this proposer or any principals thereof have any current, past personal or professional relationship with any Commissioner or Officer of the AHA?

☐Yes ☐ No

If yes, please include clarifying information including dates, with who and state the circumstances and any

(23) Additional clarifying information regarding questions and statements (12) through (22) – include below and/or attach related documents:

(24) Non-Collusive Affidavit: The undersigned party submitting this bid hereby certifies that such bid is genuine and not collusive and that said bidder entity has not colluded, conspired, connived or agreed, directly or indirectly, with any proposer 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 proposer, to fix overhead, profit or cost element of said proposal price, or that of any other bidder or to secure any advantage against the AHA or any person interested in the proposed contract; and that all statements in said bid are true.

(25) Verification Statement: The undersigned bidder hereby states that by completing and submitting this bid 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 AHA discovers that any information entered herein is false, that shall entitle the AHA to not consider nor make award or to cancel any award with the undersigned party.

Signature: ___________________________________________________________

Printed Name: ___________________________________________________________

Title: ___________________________________________________________

Company: ___________________________________________________________

Date: ___________________________________________________________