6-00 45 13 Prequalification Application.pdf

SECTION 00 45 13

PREQUALIFICATION APPLICATION

Date of Balance Sheet , Mark only one:

Name under which you wish to qualify

Post Office Box City State Zip Code

Street Address (required) City State Zip Code

Telephone Fax Email

Texas Taxpayer Identification No.

Federal Employers Identification No.

DUNS No. (if applicable)

Email/mail this questionnaire along with financial statements to the appropriate group below. A separate submittal is required for water/sewer, paving, and lighting:

Work Category – Water Dept - Water/sewer Work Category – TPW Paving Work Category – TPW Ped/Rdwy Lighting john.kasavich@FortWorthTexas.gov TPW_Prequalification@fortworthtexas.gov clint.hoover@fortworthtexas.gov

Fort Worth Water Department Engineering and Fiscal Services Division 200 Texas St. Fort

Worth, TX 76102

City of Fort Worth Transportation and Public Works Dept. 3741 SW Loop 820, Fort Worth, Texas 76133 Attn: Alicia Garcia

City of Fort Worth TPW Transportation Management Attn: Clint Hoover, P.E. 5001

James Ave. Fort Worth, TX 76115

*Financial Statements must be mailed. Mark the envelope: “Bidder Prequalification Application”

Individual

Limited Partnership

General Partnership

Corporation

Limited Liability Company

CITY OF FORT WORTH

STANDARD CONSTRUCTION SPECIFICATION DOCUMENTS

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BIDDER PREQUALIFICATION APPLICATION

BUSINESS CLASSIFICATION

The following should be completed in order that we may properly classify your firm:

(Check the block(s) which are applicable – Block 3 is to be left blank if Block 1 and/or Block 2 is checked)

Has fewer than 100 employees and/or

Has less than $6,000,000.00 in annual gross receipts

OR

Does not meet the criteria for being designated a small business as provided in Section

2006.001 of the Texas Government Code.

The classification of your firm as a small or large business is not a factor in determining eligibility to become prequalified.

Select major work categories for which you would like to be prequalified (City may deem you are not qualified for selected category or may approve you at a lesser size/length and maximum size may not be listed specifically under a major work category):

MAJOR WORK CATEGORIES

Water Department

Augur Boring - 24-inch diameter casing and less

Augur Boring - Greater than 24-inch diameter casing and greater

Tunneling – 36-Inches – 60 –inches, and 350 LF or less

Tunneling - 36-Inches – 60 –inches, and greater than 350 LF

Tunneling – 66” and greater, 350 LF and greater

Tunneling – 66” and greater, 350 LF or Less

Cathodic Protection

Water Distribution, Development, 8-inch diameter and smaller

Water Distribution, Urban and Renewal, 8-inch diameter and smaller

Water Distribution, Development, 12-inch diameter and smaller

Water Distribution, Urban and Renewal, 12-inch diameter and smaller

Water Transmission, Development, 24-inch and smaller

Water Transmission, Urban/Renewal, 24-inch and smaller

Water Transmission, Development, 42-inches and smaller

Water Transmission, Urban/Renewal, 42-inches and smaller

Water Transmission, Development, All Sizes

Water Transmission, Urban/Renewal, All Sizes

Sewer Bypass Pumping, 18-inch and smaller

Sewer Bypass Pumping, 18-inch – 36-inch

Sewer Bypass Pumping 42-inch and larger

CCTV, 8-inch and smaller

CCTV, 12-inch and smaller

CCTV, 18-inch and smaller

CCTV, 24-inch and smaller

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MAJOR WORK CATEGORIES, CONTINUED

NOTE *There is not a prequalification requirement for installation of concrete sidewalk, curb & gutter, driveways, and panel replacement, only concrete paving

CCTV, 42-inch and smaller

CCTV, 48-inch and smaller

Sewer CIPP, 12-inch and smaller

Sewer CIPP, 24-inch and smaller

Sewer CIPP, 42-inch and smaller

Sewer CIPP, All Sizes

Sewer Collection System, Development, 8-inches and smaller

Sewer Collection System, Urban/Renewal, 8-inches and smaller

Sewer Collection System, Development, 12-inches and smaller

Sewer Collection System, Urban/Renewal, 12-inches and smaller

Sewer Interceptors, Development, 24-inches and smaller

Sewer Interceptors, Urban/Renewal, 24-inches and smaller

Sewer Interceptors, Development, 42-inches and smaller

Sewer Interceptors, Urban/Renewal, 42-inches and smaller

Sewer Interceptors, Development, 48-inches and smaller

Sewer Interceptors, Urban/Renewal, 48-inches and smaller

Sewer Pipe Enlargement 12-inches and smaller

Sewer Pipe Enlargement 24-inches and smaller

Sewer Pipe Enlargement, All Sizes

Sewer Cleaning, 24-inches and smaller

Sewer Cleaning, 42-inches and smaller

Sewer Cleaning, All Sizes

Sewer Cleaning, 8-inches and smaller

Sewer Cleaning, 12-inches and smaller

Sewer Siphons 12-inches or less

Sewer Siphons 24-inches or less

Sewer Siphons 42-inches or less

Sewer Siphons All Sizes

Facility Construction of Lift Stations

Sanitary Sewer Manhole/Structure Interior Lining – Warren Coating

Sanitary Sewer Manhole/Structure Interior Lining – Chesterton Coating

Transportation Public Works

Asphalt Paving Construction/Reconstruction (LESS THAN 15,000 square yards)

Asphalt Paving Construction/Reconstruction (15,000 square yards and GREATER)

Asphalt Paving Heavy Maintenance (UNDER $1,000,000)

Asphalt Paving Heavy Maintenance ($1,000,000 and OVER)

Concrete Paving Construction/Reconstruction (LESS THAN 15,000 square yards)*

Concrete Paving Construction/Reconstruction (15,000 square yards and GREATER)*

Roadway and Pedestrian Lighting

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1. List equipment you do not own but which is available by renting

DESCRIPTION OF EQUIPMENT NAME AND DETAILED ADDRESS OF OWNER

2. How many years has your organization been in business as a general contractor under your present name?

List previous business names:

3. How many years of experience in construction work has your organization had:

(a) As a General Contractor: (b) As a Sub-Contractor:

4. *What projects has your organization completed in Texas and elsewhere?

CONTRACT

AMOUNT

CLASS

OF

WORK

DATE

COMPLETED

LOCATION

CITY-COUNTY-

STATE

NAME AND DETAILED

ADDRESS OF OFFICIAL TO

WHOM YOU REFER

*If requalifying only show work performed since last statement.

5. Have you ever failed to complete any work awarded to you?

If so, where and why?

6. Has any officer or owner of your organization ever been an officer of another organization that failed to complete a contract?

If so, state the name of the individual, other organization and reason.

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7. Has any officer or owner of your organization ever failed to complete a contract executed in his/her name?

If so, state the name of the individual, name of owner and reason.

8. In what other lines of business are you financially interested?

9. Have you ever performed any work for the City?

If so, when and to whom do you refer?

10. State names and detailed addresses of all producers from whom you have purchased principal materials during the last three years.

NAME OF FIRM OR COMPANY DETAILED ADDRESS

11. Give the names of any affiliates or relatives currently debarred by the City. Indicate your relationship to this person or firm.

12. What is the construction experience of the principal individuals in your organization?

NAME

PRESENT

POSITION OR

OFFICE

YEARS OF

EXPERIENCE

MAGNITUDE

AND TYPE OF

WORK

IN WHAT

CAPACITY

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13. If any owner, officer, director, or stockholder of your firm is an employee of the City, or shares the same household with a City employee, please list the name of the City employee and the relationship. In addition, list any City employee who is the spouse, child, or parent of an owner, officer, stockholder, or director who does not live in the same household but who receives care and assistance from that person as a direct result of a documented medical condition. This includes foster children or those related by adoption or marriage.

CORPORATION BLOCK PARTNERSHIP BLOCK

If a corporation: If a partnership:

Date of Incorporation State of Organization

Charter/File No. Date of organization

President Is partnership general, limited, or registered limited liability partnership?

Vice Presidents

File No. (if Limited Partnership)

General Partners/Officers

Secretary Limited Partners (if applicable)

Treasurer

LIMITED LIABILITY COMPANY BLOCK

If a corporation:

State of Incorporation

Date of organization

File No. Individuals authorized to sign for Partnership

Officers or Managers (with titles, if any)

Except for limited partners, the individuals listed in the blocks above are presumed to have full signature authority for your firm unless otherwise advised. Should you wish to grant signature authority for additional individuals, please attach a certified copy of the corporate resolution, corporate minutes, partnership agreement, power of attorney or other legal documentation which grants this authority.

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14. Equipment $

TOTAL

Similar types of equipment may be lumped together. If your firm has more than 30 types of equipment, you may show these 30 types and show the remainder as "various". The City, by allowing you to show only 30 types of equipment, reserves the right to request a complete, detailed list of all your equipment.

The equipment list is a representation of equipment under the control of the firm and which is related to the type of work for which the firm is seeking qualification. In the description include, the manufacturer, model, and general common description of each.

ITEM QUANTITY ITEM DESCRIPTION

BALANCE SHEET

VALUE

Various-

TOTAL

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BIDDER PREQUALIFICATION AFFIDAVIT

STATE OF

COUNTY OF

The undersigned hereby declares that the foregoing is a true statement of the financial condition of the entity herein first named, as of the date herein first given; that this statement is for the express purpose of inducing the party to whom it is submitted to award the submitter a contract; and that the accountant who prepared the balance sheet accompanying this report as well as any depository, vendor or any other agency herein named is hereby authorized to supply each party with any information, while this statement is in force, necessary to verify said statement.

, being duly sworn, deposes and says that he/she is the of , the entity described in and which executed the foregoing statement that he/she is familiar with the books of the said entity showing its financial condition; that the foregoing financial statement taken from the books of the said entity as of the date thereof and that the answers to the questions of the foregoing Bidder Prequalification Application are correct and true as of the date of this affidavit.

Firm Name:

Signature:

Sworn to before me this day of , Notary Public

Notary Public must not be an officer, director, or stockholder or relative thereof.