7 Statement of Vendor.pdf

CITY OF SCHENECTADY

STATEMENT OF VENDOR QUALIFICATIONS

BUSINESS ENTITY INFORMATION

Legal Business Name EIN

Address of the Principal Place of Business (street, city, state, ZIP)

New York State Vendor Identification Number

Telephone ext.

Fax

Website

Authorized Contact for this Questionnaire

Name

Telephone ext.

Fax

Title Email

Please note: Persons or firms submitting bids must be engaged in the lines of work required in these specifications, or shall be able to refer to work of similar character performed by them. Proposers must present satisfactory evidence of experience, ability, and financial standing, and also a statement as to their plant and machinery.

Additional Business Entity Identities: If applicable, list any other DBA, Trade Name, Former Name, Other Identity, or EIN used in the last five (5) years, the state and county where filed, and the status (active or inactive).

Type Name EIN State or County where filed

Status

(Continued from previous page) Additional Business Entity Identities: If applicable, list any other DBA, Trade Name, Former Name, Other Identity, or EIN used in the last five (5) years, the state and county where filed, and the status (active or inactive).

Type Name EIN State or County where filed

Status

I. BUSINESS CHARACTERISITICS

1.0 Business Entity Type – Check appropriate box and provide additional information:

a) [ ] Corporation Date of incorporation

b) [ ] Public Corporation Date of incorporation

c) [ ] Sub-chapter “S” Corporation Date of incorporation

d) [ ] Limited Liability Company (LLC or PLLC)

Date Organized

e) [ ] Limited Liability Partnership Date of Registration

f) [ ] Limited Partnership Date Established

g) [ ] General Partnership Date Established

h) [ ] Sole Proprietor How many years in business?

i) [ ] Other Date Established

If Other, explain:

The Contractor’s federal employer identification number is: ______________________________

DUNS Number: __________________________________________________________________

1.1 Was the Business Entity formed in New York State?

[ ] Yes [ ] No

If “No,” indicate jurisdiction where the Business Entity was formed:

[ ] United States State

[ ] Other Country

1.2 If the Legal Business Entity’s Principal Place of Business is not in New York State, does the Legal Business Entity maintain an office in New York State?

(Select N/A if Principal Place of Business is in New York State.)

[ ] N/A

2. LEADERSHIP INTEGRITY

Within the past five (5) years, has any current or former reporting entity official or any individual currently or formerly having the authority to sign, execute, or approve bids, proposals, contracts, or supporting documentation on behalf of the reporting entity with any government entity been:

2.0 Sanctioned relative to any business or professional permit and or license?

[ ] Yes [ ] No [ ] Other

2.1 Suspended, debarred, or disqualified from any government-contracting process?

If “Yes,” provide the address and telephone number for one office located in New York State.

1.3 Is the Legal Business Entity a New York State certified

Minority-Owned Business Enterprise (MBE), Women-Owned Business Enterprise (WBE), New York State Small Business (SB), or a federally certified Disadvantaged Business Enterprise (DBE)?

If “Yes,” check all that apply:

[ ] New York State certified Minority-Owned Business (MBE) [ ] New York State certified Women-Owned Business Enterprise (WBE) [ ] New York State Small Business (SB) [ ] Federally certified Disadvantaged Business Enterprise (DBE)

1.4 Identify Officials and Principal Owners, if applicable. For each person, include name, title, and percentage of ownership. Attach additional pages if necessary. If applicable, reference to relevant SEC filing(s) containing the required information is optional.

Name Title Percentage of Ownership (Enter 0% if not applicable)

2.2 The subject of an investigation, whether open or closed, by any government entity that resulted in findings of civil or criminal violation for any business-related conduct?

2.3 Indicted, granted immunity, or convicted of a felony or

misdemeanor crime, or subject to a judgment for:

a. Any business-related activity; or

b. Any crime, whether or not business-related, the underlying conduct of which was related to truthfulness?

For each “Yes” or “Other” explain:

3. INTEGRITY – CONTRACT BIDDING

Within the past five (5) years, has the reporting entity:

3.0 Been suspended or debarred from any government-contracting process or been disqualified on any government procurement, permit, license, concession, franchise or lease, including but not limited to, debarment for violation of New York State Workers’ Compensation or Prevailing Wage laws, or New York State Procurement Lobbying Law?

3.1 Been subject to a denial or revocation of a government

prequalification?

3.2 Been denied a contract award or had a bid rejected based upon a non-responsibility finding by a government entity?

3.3 Had a low bid rejected on a government contract for failure to make good-faith efforts on any Minority-Owned Business Enterprise, Women-Owned Business Enterprise, or Disadvantaged Business Enterprise goal or statutory affirmative-action requirements on a previously held contract?

3.4 Agreed to a voluntary exclusion from bidding/contracting with a government entity?

3.5 Initiated a request to withdraw a bid submitted to a government entity in lieu of responding to an information request or subsequent to a formal request to appear before the government entity?

For each “Yes” explain:

4. INTEGRITY – CONTRACT AWARD

4.0 Been suspended or terminated for cause on any government

contract including, but not limited to, a non-responsibility finding?

4.1 Been subject to an administration proceeding or civil action seeking specific performance or restitution in connection with any government entity?

4.2 Entered into a formal monitoring agreement as a condition of a contract award from a government entity?

For each “Yes,” explain:

5. CERTIFICATIONS/LICENSES

5.0 Had a revocation, suspension, or disbarment of any business or professional permit and/or license?

5.1 Had a denial, decertification, revocation, or forfeiture of New York State certification of Minority-Owned Business Enterprise, Women-Owned Business Enterprise, or federal certification of Disadvantaged Business Enterprise status for other than change of ownership?

For each “Yes,” explain and be sure to attach all relevant licenses and certifications related to this bid, regardless of whether or not there has a problem:

5.2 Does the Reporting Entity carry the following insurances:

- Workers Compensation

- Disability Benefits Insurance

- General Liability

- Comprehensive Automobile Liability

5.3 Attach any and all related insurance certificates appropriate to the services offered (i.e.: professional malpractice, workers compensation, property coverage, general liability, data breach, etc.) and/or as requested by the purchasing office.

6. LEGAL PROCEEDINGS

6.0 Been the subject of an investigation, whether open or closed, by any government entity for a civil or criminal violation?

6.1 Been the subject of an indictment, grant of immunity, judgment, or conviction (including entering into a plea bargain) for conduct constituting a crime?

6.2 Received an OSHA citation and Notification of Penalty

containing a violation classified as serious or willful?

6.3 Had a government entity find a willful prevailing-wage or supplemental-payment violation or any other willful violation of New York State Labor Law?

6.4 Entered into a consent order with the New York State

Department of Environmental Conservation, or received an enforcement determination by any government entity involving a violation of federal, state, or local environmental laws?

6.5 Other than previously disclosed:

a) Been subject to fines or penalties imposed by government entities, which in the aggregate total $25,000 or more, or;

b) Been convicted of a criminal offense pursuant to any administrative and/or regulatory action taken by any governmental entity?

For each “Yes,” explain:

7. FINANCIAL AND ORGANIZATIONAL CAPACITY

7.0 Within the past five (5) years has the Reporting Entity received any formal unsatisfactory-performance assessment(s) from any government entity on any contract?

If “Yes,” provide and explanation of the issue(s), relevant dates, the government entity involved, any remedial or corrective action(s) taken and the current status of the issue(s). Provide answer below or attach additional sheets with numbered responses.

7.1 Within the past five (5) years, has the Reporting Entity had any liquidated damages assessed over $25,000?

If “Yes,” provide an explanation of the issue(s), relevant dates, contracting party involved, the amount assessed, and the current state of the issue(s). Provide answer below or attach additional sheets with numbered responses.

7.2 Within the past five (5) years, have any liens or judgments (not including UCC filings) over $25,000 been filed against the Reporting Entity that remain undischarged?

If “Yes,” provide and explanation of the issue(s), relevant dates, the Lien Holder or Claimant’s names(s), the amount of the lien(s), and the current status of the issue(s).

Provide answer below or attach additional sheets with numbered responses.

7.3 In the last seven (7) years, has the Reporting Entity initiated or been the subject of any bankruptcy proceedings, whether or not closed, or is any bankruptcy proceeding pending?

If “Yes,” provide the bankruptcy chapter number, the court name, and the docket number. Indicate the current status of the proceedings as “Initiated,” “Pending,” or “Closed.” Provide answer below or attach additional sheets with numbered responses.

7.4 During the past three (3) years, has the Reporting Entity failed to file any tax returns required by federal, state, or local laws?

If “Yes,” provide the taxing jurisdiction, the type of tax, the liability year(s), the tax liability amount the Reporting Entity failed to file/pay and the current status of the tax liability. Provide answer below or attach additional sheets with numbered responses.

7.5 During the past three (3) years, has the Reporting Entity failed to file any New York State unemployment insurance returns?

If “Yes,” provide the years the Reporting Entity failed to file/pay the insurance, explain the situation and any remedial or corrective action(s) taken, and the current status of the

7.6 During the past three (3) years, has the Reporting Entity had any government audit(s) completed?

a) If “Yes,” did any audit of the Reporting Entity identify any reported significant deficiencies in internal control, fraud, illegal acts, significant violations of provisions of contracts or grant agreements, significant abuse, or any material disallowance?

[ ] Yes [ ] No

If “Yes,” to 7.6 a), provide an explanation of the issue(s), relevant dates, the government entity involved, any remedial or corrective action(s) taken, and the current status of the

8. ASSOCIATED ENTITIES

This section pertains to any entity(ies) that either control, or is controlled by, the reporting entity.

8.0 Does the Reporting Entity have any Associated Entities?

Note: All questions in this section must be answered if the Reporting Entity is either:

- An Organizational Unit; or

- The entire Legal Business Entity that controls, or is controlled by, any other entity(ies).

If “No,” SKIP THE REMAINDER OF SECTION 8.

8.1 Within the past five (5) years, has any Associated Entity Official or Principal Owner been charged with a misdemeanor or felony, been indicted, granted immunity, convicted of a crime, or subject to a judgment for:

a) Any business-related activity; or

b) Any crime, whether or not business related, the underlying conduct of which was related to truthfulness?

If “Yes,” provide an explanation of the issue(s), the individual involved, his/her role in the Associated Entity, his/her relationship to the Reporting Entity, relevant dates, the government entity involved, any remedial or corrective action(s) taken, and the current status of the issue(s). Provide answer below or attach additional sheets with numbered responses.

8.2 Does any Associated Entity have any currently undischarged Federal, New York State, New York City, or other New York local government liens or judgments (not including UCC filings) over $50,000?

If “Yes,” provide an explanation of the issue(s), identify the Associated Entity’s name(s), EIN(s), primary business activity, relationship to the Reporting Entity, relevant dates, the Lien holder or Claimant’s name(s), the amount of the lien(s) and the current status of the issue(s). Provide answer below or attach additional sheets with numbered responses.

8.3 Within the past five (5) years, has any Associated Entity:

a) Been disqualified, suspended, or debarred from any federal, New York State, New York City, or other New York local government- contracting process?

b) Been denied a contract award, or had a bid rejected, based upon a non-responsibility finding by any federal, New York State, New York City, or other New York local government entity?

c) Been suspended, cancelled, or terminated for cause (including non-responsibility) on any federal, New York State, New York City, or New York local government contract?

d) Been the subject of an investigation, whether open or closed, by any federal, New York State, New York City, or New York local government entity for a civil or criminal violation with a penalty in excess of $500,000?

e) Been the subject of an indictment, grant of immunity, judgment, or conviction

(including entering into a plea bargain) for conduct constituting a crime?

f) Been convicted of a criminal offense pursuant to any administrative and/or regulatory action taken by any federal, New York State, New York City, or other New York local government entity?

g) Initiated, or been subject of, any bankruptcy proceedings, whether or not closed, or is any bankruptcy proceeding pending?

For each “Yes,” provide an explanation of the issue(s), identify the Associated Entity’s name(s), EIN(s), primary business activity, relationship to the Reporting Entity, relevant date(s), the government entity involved, any remedial or corrective action(s) taken, and the current status of the issue(s). Provide answer below or attach additional sheets with numbered responses.

9. REFERENCES AND PROFESSIONAL MEMBERSHIPS

9.0 Bank References

A.______________________________________________________________________

B.______________________________________________________________________

C.______________________________________________________________________

D.______________________________________________________________________

E.______________________________________________________________________

F.______________________________________________________________________

G.______________________________________________________________________

9.1 Trade Association Memberships

A.______________________________________________________________________

B.______________________________________________________________________

C.______________________________________________________________________

D.______________________________________________________________________

10. CERTIFICATION

10.0 Attach state of financial conditions, including vendor’s latest regulated dated financial statement or balance sheet.

Date of current statement or balance sheet:____________________________________

Name and address of firm preparing statement: ________________________________

Dated at____________________This______________Day of_____________20_______

Name of Organization:_____________________________________________________

By:

Title:

State of: )

:ss

County of: )

M______________________________________being duly sworn deposes and says that he/she is the __________________________of _______________________contractor and that answers to the forgoing questions and all statements therein contained are true and correct.

Sworn to before me this _____________________day of______________________20_______

Notary Public: __________________________________________________________________

My Commission expires: _________________________________________________________

Notary Seal/Stamp