4-Prequalification Statement.pdf

ATTACHMENT A

APPLICANT'S PRE-QUALIFICATION STATEMENT

Old Town Pool Reconstruction

Submitted By:

Applicant Name and Address:

Applicant telephone No.: ( ) Fax No.: ( )

Applicant's Virginia Contractor's License Number: Class:

Tax ID No. (Soc. Sec. No. If Sole Proprietor): _

Person who can respond authoritatively to any questions about this statement:

Name: Title: Tel.:

Email:

Indicate if: Corporation Sole Proprietor Partnership

Joint Venture Other (Indicate)

The Applicant may attach additional information deemed appropriate to respond. Do not attach additional information irrelevant to the response.

1. Organization

A. How many years has your organization been in business as a construction contractor?

B. How many years has your organization been in business under its present business name?

C. Under what other or former names has your organization operated?

D. If your organization is a corporation, please indicate:

Date of incorporation:

State of incorporation:

President's name:

Vice President's name(s):

Secretary's name:

Treasurer's name:

E. If your organization is a partnership, please indicate:

Date of organization:

Type of partnership (if applicable):

Name(s) of general partners:

F. If your organization is a sole proprietorship, please indicate:

Date of organization:

Name of owner:

G. If the form of your organization is other than those listed above, describe it and name the principals and date of commencement of business:

H. Is the applicant related to another firm as a parent, subsidiary or affiliate?

Yes No

If yes, give names and addresses of all affiliated parent and/or subsidiary companies. Indicate which companies are subsidiaries.

2. Judgments

A. Has the applicant or any officer, director or owner thereof had any judgments entered against him within the past ten years for breach of contracts for governmental or non-governmental construction, including, but not limited to, design-build or construction management?

If yes, provide details on any such judgment.

3. Contract Compliance

A. Has your firm been found to be in substantial noncompliance with the terms and conditions of prior construction contracts in the past 10 years?

If yes, provide details on any such instance.

B. Has the Applicant ever failed to complete any work awarded to it? If yes, state date(s), project(s), owner or A/E reference(s), and reason(s).

Yes No

C. Has the Applicant ever been declared to be in default or partial default on a construction contract or project? If yes, state date(s), project(s), owner or A/E reference(s), and reason(s).

Yes No

D. Has the Owner or Owner’s Agent ever taken steps to complete contract work, which was the Applicants own responsibility? If yes, indicate date(s), project(s), owner or A/E references, and reason(s).

Yes No

E. Are there any judgments, claims, suites, arbitration proceedings, or other legal proceedings pending or outstanding to which the Applicant is a party? If yes, state date(s), project(s), and reason(s).

Yes No F. Has the Applicant filed or caused to be filed, any suits, arbitration requests or claims with regard to any construction contracts within the past five (5) years? If yes, state date(s), project (s), and reason(s).

4. Convictions

Has the applicant or any officer, director or owner thereof been convicted within the past ten (10) years of a crime related to governmental or non-governmental construction or contracting, including, but not limited to, violation of (i) Ethics in Public Contracting (Article 4 - § 11-72 et seq.), (ii) the Virginia Governmental

Government (Chapter 4.2 - § 59.1 - 68.6 et seq.) of Title 59.1), or (iv) any substantially similar law of the United States or another state? If yes, provide details on any such convictions on a separate sheet.

5. Debarment

Is the applicant or any officer, director or owner thereof currently debarred pursuant to an established debarment procedure from bidding or contracting by any public body, agency of another state or agency of the federal government?

If yes, provide details:

A. Is the Applicant currently a debtor in any bankruptcy case or has been in bankruptcy at anytime during the previous five (5) years? If yes, state date(s), and reason(s).

6. Surety and Insurance

A. Provide documentation from your Surety identifying Applicant’s total bonding capacity, individual job bonding capacity, and maximum the Applicant can be bonded on a single project.

B. Provide the following information:

Average annual contract volume for the past 5 years $

Total value of work in progress or under contract $

C. Has any surety company made a payment on Applicant’s behalf as a result of default, to satisfy any claims made against a performance or payment bond in connection with any construction project during the previous five (5) years? If yes, state date(s), project(s), and reasons.

Yes No

D. Has any insurance carrier, for any form of insurance, refused to renew insurance policy for your firm? If yes, state date(s), and reason(s).

7. Confidential and Proprietary Information

Initial here if the applicant requests that all information submitted as part of this prequalification process be considered a trade secret or as proprietary information subject to the provisions of subsection D of § 2.2-4342, Code of Virginia.