SPO Form-21

SAMPLE

STATE OF HAWAII

STANDARD

QUALIFICATION QUESTIONNAIRE

FOR

OFFERORS

issued by the

PROCUREMENT POLICY BOARD

June 16, 2003

To be filed with the procurement officer calling for offers in accordance with Section 103D-310, HRS, as amended.

Submitted By ______________________________________________________________

Address ___________________________________________________________________

Date

STANDARD QUALIFICATION QUESTIONNAIRE

COVERING EXPERIENCE, EQUIPMENT AND FINANCIAL STATEMENT OF OFFERORS. THE OFFICER

CALLING FOR OFFERS MAY REQUIRE THE OFFEROR TO FURNISH ADDITIONAL INFORMATION

NOT SPECIFICALLY COVERED HEREIN. ALL ITEMS MUST BE ANSWERED AND OMISSIONS MAY BE

CONSIDERED GOOD CAUSE FOR UNFAVORABLE CONSIDERATION.

GENERAL INFORMATION

1. The statements contained in this Questionnaire are being furnished for consideration in submitting an offer for the following project:

(a) Project Title __________________________________________________________________________

(b) Location _____________________________________________________________________________

(c) Bid Opening Date _____________________________________________________________________

2. The Questionnaire is being submitted in behalf of:

A Corporation

(a) Name of Offeror___________________________________________________ A Partnership An Individual A Joint-Venture

(b) Address _____________________________________________________________________________

(c) Telephone No. _______________________________________________________________________

(d) Date Submitted _______________________________________________________________________

3. If the bid is submitted by a joint venture, composed of two or more individual firms, then each member firm comprising the joint venture must submit all information listed on pages 3 through 16, inclusive, of the Questionnaire and, in addition, answer the following:

(a) Members of joint Venture ________________________________________________________________

(b) Date of Joint Venture Agreement __________________________________________________________

(c) Is agreement between members comprising the joint venture joint and several liability? ______________ If not, state the terms of agreement in this respect: ____________________________________________

EXPERIENCE QUESTIONNAIRE

A C o r p o r a t i o n S u b m i t t e d b y _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ A P a r t n e r s h i p A n I n d i v i d u a l P r i n c i p a l O f f i c e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

The signatory of this questionnaire guarantees the truth and accuracy of all statements and of all answers to interrogatories hereinafter made

1. How many years has your organization been in business as a [General Contractor] under your present business name? __________________________________________________________________________________

2. How many years experience in [construction] ________________ has your organization had: (A) as a [General Contractor ]_____________; (B) as a [Sub-Contractor] ______________

3. Show what [construction] projects your organization has completed in the past five (5) years in the following tabulation:

Contract Amt. Class of Work When Completed Name and Address of Owner

4. Have you ever failed to complete any work awarded to you? ___________________ If so, state when, where and why? _____________________________________________________________________

5. Has any officer or partner of your organization in the past five (5) years been an officer or partner of some other organization that failed to complete a contract? If so, state name of individual, other organization and reason therefore ____________________________________________________________________________________

6. Has any officer or partner of your organization in the past five (5) years failed to complete a contract handled in his own name? ____________ If so, state name of individual, name of Owner and reason therefore.

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

8. For what corporations or individuals in the past five (5) years have you performed work, and to whom do you refer? ______________________________________________________________________________________

9. For what counties within the State of Hawaii have you performed work and to whom do you refer?

10. For what Bureaus or Departments of the State government -have you performed work and to whom do you refer?

11. Have you performed work for the U. S. Government? ____________ If so, when and to whom do you refer?

12. Have you ever performed any work for any other governmental agencies outside the State of Hawaii? ________ If so, when and to whom do you refer? ___________________________________________________________

13. What is the [construction] experience of the principal individuals of your organization?

Individual’s Name Present Position or Office

Years of Work

Experience

Magnitude and Type of Work In What Capacity?

EQUIPMENT QUESTIONNAIRE

S u b m i t t e d b y _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ A P a r t n e r s h i p A n I n d i v i d u a l P r i n c i p a l O f f i c e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

The signatory of this questionnaire guarantees the truth and accuracy of all statements and of all answers to interrogatories hereinafter made

1. In what manner have you inspected this proposed work? Explain in detail. ____________________________

2. Explain your plan or layout for performing the proposed work. _____________________________________

3. The work, if awarded to you, will have the personal supervision of whom?

4. Do you intend to do the hauling on the proposed work with your own force? __________ If so, give amount and type of equipment to be used. _____________________________________________________________

5. If you intend to sublet the hauling or perform it through an agent, state amount of sub-contract or agent's contract, and, if known, the name and address of sub-contractor or agent, amount and type of his equipment and financial responsibility ___________________________________________________________________

6. Do you intend to do grading on the proposed work with your own forces? ______________ If so, give type of equipment to be used ______________________________________________________________________

7. If you intend to sublet the grading or perform it through an agent, state amount of sub-contract or agent's contract, and, if known, the name and address of sub-contractor or agent, amount and type of his equipment and financial responsibility ___________________________________________________________________

8. Do you intend to sublet any other portions of the work? ______________________ If so, state -amount of sub-contract, and, if known, the name and address of the sub-contractor, amount and type of his equipment and financial responsibility ___________________________________________________________________

9. From which sub-contractors or agents do you expect to require a bond? _______________________________

10. What equipment do you own that is available for the proposed work?

Quantity Item Description, Size, Capacity, Etc.

Condition Years of

Service Present Location

11. What equipment do you intend to purchase for use on the proposed work, should the contract be awarded to you?

Quantity Item Description, Size, Capacity, Etc. Approximate Cost

12. How and when will you pay for the equipment to be purchased? _____________________________________

13. Do you propose to rent any equipment for this work? _________________________ If so, state type, quantity and reasons for renting_______________________________________________________________________

FINANCIAL STATEMENT

S u b m i t t e d b y _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ A P a r t n e r s h i p A n I n d i v i d u a l P r i n c i p a l O f f i c e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

The signatory of this questionnaire guarantees the truth and accuracy of all statements and of all answers to interrogatories hereinafter made

BALANCE SHEET

As of ________________________, 20______

Assets

Current assets:

Cash and cash equivalents (1) $ ________________ Short-term investments (2) ________________ Accounts receivable, net (3) ________________ Inventories (4) ________________

Costs and estimated earnings in excess of billings on uncompleted contracts (5) ________________

Prepaid expenses and other (6) Sub-Total Current Assets

Property and equipment:

Land (7) ________________ Buildings (8) ________________ Vehicles, machinery and equipment (9) ________________ Furniture and fixtures (10) ________________ Less accumulated depreciation ( ) Sub-Total Net Property and Equipment

Other assets:

Cash surrender value of life insurance policies (11) ________________ Deposits and other (12) Sub-Total Other Assets

Total Assets: $

BALANCE SHEET (Continued)

Liabilities and Stockholder’s Equity

Current liabilities:

Current portion of long-term debt (1) $ ________________ Accounts payable (2) ________________

Billings in excess of costs and estimated earnings on uncompleted contracts (3) ________________

Accrued liabilities and other (4) Sub-Total Current Liabilities

Long-term debt, net of current portion (5)

Sub-Total Liabilities & Long-term Debt: $ ________________

Stockholder’s equity:

Capital stock (6) ________________ Additional paid-in capital (7) ________________ Retained earnings ________________ Treasury stock (8) ( ) Sub-Total Stockholder’s Equity $

Total Liabilities and Stockholder’s Equity $

DETAILS RELATIVE TO ASSETS

(1) Cash and cash equivalents:

Financial Institution Type of Account Amount

(2) Short-term investments:

Unrealized Unrealized Estimated Type of Security Cost Gains Losses Fair Value

(3) Accounts receivable (list major debtors):

Completed contracts Completion Contract Amount Name Description Date Amount Receivable

Other than completed contracts Amount Name Description Due Date Receivable

Less allowance for doubtful accounts ( )

(4) Inventories Lower of Cost

Description Cost Market Value or Market Value

DETAILS RELATIVE TO ASSETS (Continued)

(5) Costs and estimated earnings in excess of billings on uncompleted contracts Costs and Costs and Estimated Completion Contract Estimated Billings Earnings in Name Description Date Amount Earnings to Date to Date Excess of Billings

(6) Prepaid expenses and other Description Amount

(7) Land

Description Location Amount

(8) Buildings

Description Location Amount

(9) Vehicles, machinery and equipment

Description Amount

(10) Furniture and fixtures Description Amount

DETAILS RELATIVE TO ASSETS (Continued)

(11) Cash surrender value of life insurance policies Paid-Up Policy Additional CSV Key Employee Insurance Company Amount Insurance Amount Less loans payable _____________ ____________ ( )

(12) Deposits and other

Description Amount

DETAILS RELATIVE TO LIABILITIES AND STOCKHOLDER’S EQUITY

(1) Current portion of long-term debt (maturing within 12 months)

Security Lender Description Pledged Due Date Amount

(2) Accounts payable (list major creditors)

Past Due Name Amount Amount

(3) Billings in excess of costs and estimated earnings on uncompleted contracts

Costs and Billings in excess Completion Contract Estimated Billings of costs and Name Description Date Amount Earnings to Date to Date Estimated Earnings

(4) Accrued liabilities and other

Description Amount

(5) Long-term debt, net of current portion

Security Lender Description Pledged Due Date Amount

DETAILS RELATIVE TO LIABILITIES AND STOCKHOLDER’S EQUITY (Continued)

(6) Capital stock

No. of Shares No. of Shares Issued and Type of Stock Class Authorized Outstanding Par Value Amount

(7) Additional paid-in capital

Description Amount

(8) Treasury stock

No. of Type of Stock Class Shares Cost

STATEMENTS OF INCOME AND RETAINED EARNINGS

For the Years Ended ________________________, 20____ and 20 ____

20____ 20____

Contract revenues $ ____________ $ ___________

Costs of contracts Gross income from contracts

General and administrative expenses Income from operations

Other income (expense) Income before income taxes

Income taxes Net income

Retained earnings, beginning of the year

Retained earnings, end of the year $ $

If a partnership, answer this:

Date o f organization ___________________________________

Date registered in Hawaii ________________________________

State whether partnership is general or limited ______________

If a corporation, answer this:

Capital paid in cash, $ _______________________________

When Incorporated __________________________________

In what State _______________________________________

Date registered in Hawaii ____________________________

President's name ___________________________________

Vice-President's name _______________________________

Secretary's name ___________________________________

Treasurer's name ___________________________________

Name and address of partners:

Age

The undersigned hereby declares: that the foregoing is a true statement of the financial condition of the individual, partnership or corporation 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 offeror a contract; and that any depository, vendor or other agency herein named is hereby authorized to supply such party with any information necessary to verify this statement.

N OT E : A partnership must give firm name and signatures o f all partners. A corporation must give full corporate name, signature of o f f i c ia l , and affix corporate seal.

Affidavit for Individual

COUNTY OF____________________

_________________________________________________________________ being duly sworn, deposes and says that the foregoing financial statement, taken from his books, is a true and accurate statement of his financial condition as of the date thereof and that the answers to the foregoing interrogatories are true.

Sworn to before me this (Applicant must also sign here) ____________________ day of _______________ 20_____

Notary Public

Affidavit for Partnership

COUNTY OF____________________

__________________________________________________________________ being duly sworn, deposes and says that he is a member of the firm of ______________________________________________________________________; and that he is familiar with the books of the said firm showing its financial condition: that the foregoing financial statement, taken from the books of the said firm, is a true and accurate statement of the financial condition of the said firm as of the date thereof and that the answers to the foregoing interrogatories are true.

Sworn to before me this (Members of firm must also sign here) ____________________ day of ______________20_____

Affidavit for Corporation

C O U N T Y O F _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

___________________________________________________________________ being duly sworn, deposes and says that he is ________________________________ of the ___________________________________________________________, the corporation described in and which executed the foregoing statement; that he is familiar with the books of the said corporation showing its financial condition; that the foregoing financial statement, taken from the books of the said corporation, is a true and accurate statement of the financial condition of said corporation as of the date thereof and that the answers to the foregoing interrogatories are true.

Sworn to before me this (Officer must also sign here) ____________________ day of ___________________ 20_____