ATTACHMENT 04 Standard Qualifications Questionnaire.docx
DOCX document 72 KB Posted
- Attached to
- RFP 26-18 Visitor Assistance Program - Kaua‘i
- Solicitation number
- P26002870
- Issued by
- Kauai County, Hawaii
About this file
This is a Standard Qualification Questionnaire issued by the Procurement Policy Board of the State of Hawaii on June 16, 2003, for use in RFP 26-18 regarding a Visitor Assistance Program on Kaua'i administered by the Hawai'i Tourism Authority. The questionnaire is a mandatory submission requirement for all offerors bidding on the project and must be completed in its entirety, with omissions subject to unfavorable consideration. Offerors are required to provide comprehensive documentation of their organizational experience, equipment capabilities, and financial stability as part of the procurement process.
The questionnaire requires offerors to disclose detailed experience information including years in business, construction and contracting history, completed project portfolios from the past five years with contract amounts and completion dates, references from previous clients including corporations, counties within Hawaii, state government departments, the U.S. Government, and other governmental agencies, and qualifications of principal individuals within the organization. Additionally, offerors must submit a complete audited or compiled financial statement including balance sheets, asset details, liabilities, stockholder equity, income statements, and retained earnings documentation, along with affidavits under oath specific to the organizational structure (individual, partnership, or corporation). For corporations, incorporation details and officer information are required; for partnerships, organization dates and partner information with ages must be provided. The financial documentation must verify the truthful accuracy of all statements and authorize verification of information through financial institutions, vendors, and other agencies named in the submission.
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Other files
| File | Type | Posted |
|---|---|---|
| HTA RFP 26 18 Visitor Assistance Program Kauai FINAL 051426.pdf | ||
| EXHIBIT G VAP Tracking Sheet Template.xlsx | XLSX spreadsheet | |
| ATTACHMENT 02 Proposal Transmittal Letter.docx | DOCX document | |
| AG-008 103D General Conditions (1.10.23).pdf | ||
| ATTACHMENT 01 Offeror Check List.docx | DOCX document | |
| EXHIBIT H VAP Quarterly Report Template.docx | DOCX document | |
| ATTACHMENT 06 Subcontractor References if applicable.docx | DOCX document | |
| EXHIBIT F VAP Monthly Report Template.docx | DOCX document | |
| ATTACHMENT 03 Corporate Resolution.docx | DOCX document | |
| EXHIBIT J Financial Reports of Actual Expenses and Income.xlsx | XLSX spreadsheet | |
| ATTACHMENT 07 Confidential Information List if applicable.docx | DOCX document | |
| ATTACHMENT 08 Conflicts of Interest Disclosures and Attestation.pdf | ||
| ATTACHMENT 05 Contractor References.docx | DOCX document | |
| EXHIBIT I VAP Final Report Template.docx | DOCX document |
Show all 14
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Text version
RFP 26-18
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:
| 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? |
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
| 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 | ||||||||||
| Completion | Contract | Estimated | Billings | Earnings in Name | Description | Date | Amount | Earnings to Date | to Date | Excess of | |
| $ | $ | $ | $ | ||||||||
| $ | $ | $ | $ | ||||||||
| $ | $ | $ | $ |
(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 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 | |||
| If a partnership, answer this: | ||||||||||
| Date o f organization | Date registered in Hawaii | State whether partnership is general or limited |
| 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 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.
| Sworn to before me this | (Applicant must also sign here) | |
| day of | 20 |
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.
| Sworn to before me this | (Members of firm must also sign here) | |
| day of | 20 |
Notary Public
STATE OF HAWAII
Affidavit for Corporation
COUNTY OF
| 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 |
Notary Public
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