ATTACHMENT 04 Standard Qualifications Questionnaire.docx

RFP 27-08

STATE OF HAWAII

STANDARD QUALIFICATION QUESTIONNAIRE

FOR OFFERORS

issued by the

PROCUREMENT POLICY BOARD STATE OF HAWAII

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

SPO Form-21 Attachment 04

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) Name of Offeror

D A Corporation D A Partnership D An Individual D 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

Subm it t e d by __ __ _ _ ___ _ __ _ ___ _ __ _ ___ _ __

D A Co r p o r a t i o n D A P a r t n e r s h i p D An I nd ividual

Principal Office ___ ___ _ __ _ ___ _ __ _ ___ _ __ _ ___ _ __ _ ___ _ _ 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:

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?

Work Experience

FINANCIAL STATEMENT

Subm it t e d by __ __ _ _ ___ _ __ _ ___ _ __ _ ___ _ __

D A Co r p o r a t i o n D A P a r t n e r s h i p D An I nd ividual

Principal Office ___ ___ _ __ _ ___ _ __ _ ___ _ __ _ ___ _ __ _ ___ _ _ 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

Total Liabilities and Stockholder’s Equity $

DETAILS RELATIVE TO ASSETS

(1) Cash and cash equivalents:

(2) Short-term investments:

Unrealized Unrealized Estimated

(3) Accounts receivable (list major debtors):

Completed contracts

Other than completed contracts Amount Name Description Due Date Receivable

Less allowance for doubtful accounts ( )

(4) Inventories Lower of Cost

DETAILS RELATIVE TO ASSETS (Continued)

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

(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

(12) Deposits and other

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

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

(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

(7) Additional paid-in capital

(8) Treasury stock

No. of

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

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 i a l , and affix corporate seal.

Affidavit for Individual

STATE OF HAWAII

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.

Notary Public

Affidavit for Partnership

STATE OF HAWAII

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.

Notary Public

STATE OF HAWAII

Affidavit for Corporation

COUNTY OF

Notary Public