Appendix_I_Additional_Town_Forms_with_Bidder_Qualification_Statement.pdf

Appendix I

Additional Forms

(Conflict of Interest, Noncollusion Affidavit, CGS 31‐57B Certificate of Compliance)

CONFLICT OF INTEREST

I. Has any person(s), officer(s), and/or official(s) employed by or associated with The Town of

Manchester ever been employed, retained, induced, or directed to solicit or secure the Contract?

YES NO

II. In the event of any allegation of substance (determination of which will be made solely by the Town) that Item I has been violated, will you, Contractor, cooperate fully with the Town in establishing whether or not the allegation is true?

YES NO

If violation of Item I above is found to have occurred, the Contract may be terminated by the Town.

Contractor:

Company:

Address:

City/State/Zip:

By:

Signature

Title

NONCOLLUSION AFFIDAVIT

I, , being duly sworn, depose and state that:

I am the person responsible within my firm for the final decision as to the price(s) and amount of this bid or, if not, that I have written authorization, enclosed herewith, from that person to make the statements set out below on his or her behalf and on the behalf of my firm.

The price(s) and amount of this bid have been arrived at independently, without consultation, communication, or agreement for the purpose of restricting competition with any other contractor, bidder or potential bidder.

Neither the price(s) nor the amount of the bid have been disclosed to any other firm or person whio is a bidder or potential bidder on this project, and will not be so disclosed either directly or indirectly prior to bid opening.

No attempt has been made or will be made to solicit, cause or induce any firm or person to submit or not submit a bid on this project, or to submit a bid higher than the bid of this firm, or submit intentionally high or noncompetitive bid or other form of complimentary bid.

The bid of my firm is made in good faith and not pursuant to any agreement or discussion with, or inducement from, any firm or person to submit a complimentary bid.

My firm has not offered or entered into a subcontracting agreement regarding the purchase of material or services from any firm or person, or offered, promised, or paid cash or anything of value to any firm or person, whether in connection with this or any other project, in consideration for an agreement or promise by any firm or person to refrain from bidding or to submit a complimentary bid on the project.

My firm has not accepted nor been promised any subcontract or agreement regarding the sale of material or services to any firm or person, and has not been promised or paid in cash or anything of value to any firm or person, whether in connection with this or any other project, in consideration for my firm’s submitting a complementary bid or agreeing to do so, on this project.

I have made a diligent inquiry of all members, officers, employees, and agents of my firm with responsibilities relating to the preparation, approval, or submission of my firm’s bid on this project and have been advised by each of them that he or she has not participated in any communication, consultation, discussion, agreement, collusion, act, or other conduct inconsistent with any of the statements and representation made in this affidavit.

Contractor: By:

Company: Signature

Address:

City/State/Zip: Title

The above statement must be subscribed and sworn to before a Notary Public.

By _______________________________________ Date ___________________________ State of _________________) ) ss _________________________________________, A.D. 20__ County of _______________) Personally appeared before me __________________________________________ who subscribed to and made oath to the truth of the foregoing statement.

Notary Public

STATE OF CONNECTICUT

Certificate of Compliance with

Connecticut General Statute Section 31 - 57b

I hereby certify that all of the statements herein contained below have been examined by me, and to the best of my knowledge and belief are true and correct.

The _____________________________________________________________________ HAS / HAS NOT

Company Name (Cross out Non-applicable) been cited for three (3) or more willful or serious or serious violations of any Occupational Safety and Health Act (OSHA) or of any standard, order or regulation promulgated pursuant to such act, during the three year period preceding the bid, provided such violations were cited in accordance with the provisions of any State Occupational Safety and Health Act of 1970, and not abated within the time fixed by the citation and such citation has not been set aside following appeal to the appropriate agency of court having jurisdiction or HAS / HAS NOT (Cross out Non-applicable) received one or more criminal convictions related to the injury or death of any employee in the three-year period preceding the bid.

The list of violations (if applicable) is attached.

(Name of Firm, Organization or Corporation)

Signed: ______________________________________________________ Written Signature:

Name Typed: (Corporation Seal)

Title: ______________________________________________________ (Title of Above Person, typed)

Dated: ________________________

State of )

County of ) ss: A.D., 20_________

Sworn to and personally appeared before me for the above, ________________________________________________, (Name of Firm, Organization, Corporation)

Signer and Sealer of the foregoing instrument of and acknowledged the same to be the free act and deed of

_____________________________________________________, and his/her free act and deed as (Name of Person appearing in front of Notary or Clerk)

(Title of Person appearing in front of Notary or Clerk)

My Commission Expires: _______________________________________________

(Notary Public) (Seal)

MSE Berm Wall Construction – Phase 1 Town of Manchester, CT

BQ- 1

BIDDER’S QUALIFICATION STATEMENT

All bidders are required to complete this form properly and submit it with their proposal.

Failure of a bidder to answer any question or provide required information in sufficient detail or providing incorrect or false information may result in bid rejection. (Use additional sheets if necessary for additional space)

1. State the exact organization name, address, telephone: _____________________________

2. State the type of organization (Corporation, Partnership, Sole Proprietorship, Other):

3. State the number of years this organization has been in business under present name: _____

4. State the number of years this organization has been in business as a General Contractor: __

5. If organization has not always been a General Contractor, list the trade(s) customarily performed prior to becoming a General Contractor:

6. If organization has not always been under present name, list all other names by which the organization has been known and associated length of time:

BQ- 2

7. List all licenses (description and number) held by the organization:

8. Has the organization ever failed to complete a contract, or has any officer or partner of the organization ever been an officer or partner of another organization that failed to complete a contract (Yes/No)? If yes, indicate the circumstances leading to the project failure and the name of the company which provided the bonding for the failed contract(s):

9. List all legal or administrative proceedings currently pending or concluded within the last five years which relate to procurement or performance of any public or private construction contract:

10. List all Occupational Safety and Health Act (OSHA) violations cited within the last five years:

BQ- 3

11. List all present commitments or obligations that may delay the work:

12. List all major tasks to be completed on the job as well as who will be performing each task

(i.e. your company or a subcontractor), if a subcontractor will be utilized, please identify by name:

13. List five projects and associated references contact information for similar projects performed demonstrating ability to complete job within the time required and within the established budget. Preference is for projects of similar size and scope to this project, with minimum contract value of $750,000. Provide project name, address, original contract amount, final contract amount, date completed, owner & reference contact:

14. List previous relevant construction experience within the past 2 years:

BQ- 4

Dated at ____________________________________________________________________ this __________day of ______________________, 2023.

Name of Organization:

Signature: __________________________________________

(Print Name): _______________________________________

Title: _____________________________________________

Notary Statement:

Mr./Mrs./Ms. ___________________________________________________ being duly sworn deposes and says that he/she is the ___________________________________(Position/Title) of

__________________________________________________________(Organization Name), and that all of the answers and statements contained therein are true and accurate.

Subscribed and sworn before me this ___________ day of __________________________, 2023.

Notary Public: _______________________________________________________________

My Commission expires: ____________________________________________, ___________

Bidder Qualification Statement