8-Contractor Experience and Qualification Statement.ADA.pdf

CONTRACTOR EXPERIENCE AND QUALIFICATION STATEMENT

A. PROJECT INFORMATION

1. Project Name:

2. MSA Project Number:

B. COMPANY INFORMATION

1. Company Name:

2. Contractor Contact Information:

Contact Name:

Street Address: City/State/ZIP:

Telephone Number: Facsimile

Number: Email Address:

3. Principal Office (if different):

State of Maryland Minority Business Certification (MBE): Yes No

If yes, provide MDOT certification number:

Registered State of Maryland Small Business Reserve (SBR) Yes No4.

If yes, provide SBR registration number:

5. Tax identification Number:

C. HISTORY AND TYPE OF ORGANIZATION

1. Type of Business Entity:

2. The organization has been registered to do business in Maryland (or other

4. MSA reserves the right to require the submission of further documentation regarding the organization’s corporate registration, filings, formation documents, etc.

D. COMPANY PROFILE

1. Gross Sales of the Business for the most recently completed 3 fiscal years:

2. Total Number of Employees:

3. Name of Bonding Company:

a. Bonding Capacity:

i. Per Project: $

ii. Aggregate: $

b. Name and address of agent:

c. Have you been required to post a payment and performance bond in the past three years?

Yes No

d. Has your application for Surety Bond ever been declined?

Yes No jurisdiction) for:

3. The organization has been doing business under its present name for: years

4. Financial Statement: ATTACH a financial statement, preferably audited, including your organization’s latest balance sheet and income statement showing the following items:

a. Current Assets (e.g., cash, joint venture accounts, accounts receivable, notes receivable, accrued income, deposits, materials inventory and prepaid expenses;

b. Net Fixed Assets;

c. Other Assets;

d. Current Liabilities (e.g., accounts payable, notes payable, accrued expenses, provision for income taxes, advances, accrued salaries and accrued payroll taxes);

e. Other Liabilities (e.g., capital, capital stock, authorized and outstanding shares par values, earned surplus and retained earnings).

E. LITIGATION AND CLAIMS HISTORY

The contractor will be immediately disqualified if the answer to any of questions below is “yes” and explanation(s) are not provided.

1. In the past ten (10) calendar years has your organization been involved in mediation of a construction related dispute where the amount in dispute exceeded $50,000?

Yes No

If “yes,” explain on a separate signed page, including the identification of the involved parties, the date of the action and the result.

2. In the past ten (10) calendar years has your organization filed a lawsuit or made a demand for arbitration where the amount in dispute exceeded $50,000?

Yes No

If “yes,” explain on a separate signed page, including the identification of the involved parties, the date of the action and the result.

3. Has your organization or any of its owners, officers or partners ever been found liable in a civil suit or found guilty in a criminal action for making any false claim or material misrepresentation to any public agency or entity?

Yes No

If “yes,” explain on a separate signed page, including the identification of the involved parties, the date of the action and the result.

4. Has your organization or any of its owners, officers or partners ever been convicted of a crime involving federal, state, or local law related to contracting or construction?

Yes No

If “yes,” explain on a separate signed page, including the identification of the involved parties, the date of the action and the result.

5. Has your organization or any of its owners, officers or partners ever been convicted of federal or state crime of fraud, theft, or been found guilty of having submitted a false claim to a public agency within the last ten (10) years?

Yes No

If “yes,” explain on a separate signed page, including the identification of the involved parties, the date of the action and the result.

6. Is your organization currently in litigation with the State of Maryland?

Yes No

If “yes,” explain on a separate signed page, including the identification of the involved parties, the date of the action and the result.

7. Has your organization ever failed to complete any work awarded to it?

Yes No

If “yes,” explain on a separate signed page, including the identification of the involved parties, the date of the action and the result.

F. LICENSES, CERTIFICATIONS AND REGISTRATIONS

1. List jurisdictions and trade categories in which your organization is legally qualified to do business, and indicate registration or license numbers, if applicable:

JURISDICTION TRADE CATEGORY LICENSE/REGISTRATIO

2. General Contractors must include a copy of the firm’s Contractor’s License;

Electrical Contractors must include a copy of the firm’s Master Electrician License; Mechanical Contractors must include a copy of the firm’s HVACR Master License; Plumbing Contractors must include a copy of the firm’s Master Plumbers License.

G. WORK EXPERIENCE

1. List the categories of work that your organization normally performs with its own forces:

2. List projects/contracts your organization currently has in progress:

Project Name Owner Approximate Contract Amount

Start Date End Date

3. List the largest projects/contracts your organization has completed in the past five years:

Project Name Owner Approximate Contract Amount

Start Date End Date

4. MSA reserves the right to review resumes of any key personnel prior to contract award.

H. PROJECT REFERENCES

1. Below please provide the requested information for no less than three (3) comparable projects/contracts substantially completed (or in progress) in the immediately preceding five (5) years. For purposes herein, a “comparable project” shall be defined as a project/contract that is reasonably close to the approximate value of the Project and is reasonably equivalent in its level of technical complexity. While it is not required that each of the submitted projects demonstrates each of the above characteristics, the submitted projects, considered in aggregate, must demonstrate the full range of characteristics.

Insert project references and information in paragraphs a-c below.

a. PROJECT/CONTRACT NO. 1

Project Name Owner Approximate Dollar Value

Date of Completion

Name of Contact Person:

Phone Number:

Email Address:

Project Description:

The contact person identified above should be someone who can comment on the company’s ability to perform the required services. ALL CONTACT INFORMATION SHOULD BE

ACCURATE AND UP-TO-DATE.

b. PROJECT/CONTRACT NO. 2

Dollar Value

Date of Completion

Name of Contact Person:

Phone Number:

Email Address:

Project Description:

The contact person identified above should be someone who can comment on the company’s ability to perform the required services. ALL CONTACT INFORMATION SHOULD BE

ACCURATE AND UP-TO-DATE

c. PROJECT/CONTRACT NO. 3

Dollar Value

Date of Completion

Name of Contact Person:

Phone Number:

Email Address:

Project Description:

The contact person identified above should be someone who can comment on the company’s ability to perform the required services. ALL CONTACT

INFORMATION SHOULD BE ACCURATE AND UP-TO-DATE.

I. INSURANCE

1. Provide a Certificate of Insurance evidencing coverage’s for General Liability, Automobile, Workers’ Compensation and Excess Liability.

J. SIGNATURE

Name of Organization:

I HEREBY CERTIFY THAT I AM DULY AUTHORIZED TO EXECUTE THIS

DOCUMENT ON BEHALF OF THE ORGANIZATION IDENTIFIED HEREIN AND

THAT THE INFORMATION PROVIDED IS TRUE AND SUFFICIENTLY

COMPLETE SO AS NOT TO BE MISLEADING.

By:

(signature)

Date:

Title:

Prequalification Submittal Checklist Your prequalification submittal shall include the following:

1. Complete Contractor Experience and Qualification Statement. This form is available in Adobe PDF format and can be filled in electronically (preferred).

2. General Contractors must include a copy of the firm’s Contractor’s License; Electrical Contractors must include a copy of the firm’s Master Electrician License; Mechanical Contractors must include a copy of the firm’s HVACR Master License; Plumbing Contractors must include a copy of the firm’s Master Plumbers License.

3. Copy of the firm’s insurance certificate.