ATTACHMENT_II-PROPOSER_QUALIFICATIONS-GENERAL_QUESTIONNAIRE_REC.pdf

ATTACHMENT II

PROPOSER QUALIFICATIONS – GENERAL QUESTIONNAIRE

Name/Name of Agency/Company: ______________ (full, correct legal name)

Address: _____________________

Telephone/Fax: ______________

Website address:______________________________________________________________________ Year established:_______________________________________________________________________

Provide the number of years in business under present name:____________________________________

Social Security Number or Federal Employer Identification Number: ______________________________

Texas Comptroller’s Taxpayer Number, if applicable: ______________________________________ (NOTE: This 11-digit number is sometimes referred to as the Comptroller’s TIN or TID.)

DUNS NUMBER: _______________________________________________________________________

Business Structure: Check the box that indicates the business structure of the Respondent.

if ___Individual or Sole Proprietorship if checked, list Assumed Name, if any

_ ___ Partnership

___Corporation If checked, check one: ___For-Profit ___ Nonprofit

Also, check one: ___Domestic ___Foreign

___Other If checked, list business structure:__________________________________________________ Printed Name of Contract

Signatory: _______________________________________________________

Job Title: _____________________________

Provide any other names under which Respondent has operated within the last 10 years and length of timeunderforeach:_______________________________________________________________________________

Provide address of office from which this project would be managed:

City: ___________________________State: __________________Zip code: ________________________

Telephone No. ____________________________FaxNo: _______________________________________

Annual Revenue: $_____________________________________________________________________

Total Number of Employees: ____________________________________________________________

Total Number of Current Clients/Customers: _________________________________________________

Briefly describe other lines of business that the company is directly or indirectly affiliated with:

ListRelatedCompanies:

2. Contact Information: List the one person who the City may contact concerning your proposal or setting dates for meetings.

Name:_______________________________Title:____________________________________________

Address:______________________________________________________________________________

City:____________________________State:__________________ZipCode:_______________________

TelephoneNo._____________________________FaxNo:______________________________________

Email:________________________________________________________________________________

3. Does Respondent anticipate any mergers, transfer of organization ownership, management reorganization, or departure of key personnel within the next twelve (12) months?

Yes ___ No ___

4. Is Respondent authorized and/or licensed to do business in Texas?

Yes___No___If“Yes”,list authorizations licenses.______________________________________________ corporate headquarters located? 5.Where is the Respondent’s

6.Local/County Operation: Does the Respondent have an office located in San Antonio, Texas?

Yes ___ No ___ If “Yes”, respond to a and b below:

a. How long has the Respondent conducted business from its San Antonio office? Years _______

Months_______

b. State the number of full-time employees at the San Antonio office.

If “No”, indicate if Respondent has an office located within Bexar County, Texas: Yes ___ No ___

If “Yes”, respond to c and d below: c. How long has the Respondent conducted business from its Bexar

County office? Years _______ Months_______ d. State the number of full-time employees at the Bexar

County office. ____________________________________

7.Debarment/Suspension Information: Has the Respondent or any of its principals been debarred or suspended from contracting with any public entity?

Yes ___ No ___ If “Yes”, identify the public entity and the name and current phone number of a representative of the public entity familiar with the debarment or suspension, and state the reason for or circumstances surrounding the debarment or suspension, including but not limited to the period of time forsuchdebarmentorsuspension.__________________________________________________________

8. Surety Information: Has the Respondent ever had a bond or surety canceled or forfeited?

Yes ___ No ___ If “Yes”, state the name of the bonding company, date, amount of bond and reason for suchcancellationorforfeiture.

9. Bankruptcy Information: Has the Respondent ever been declared bankrupt or filed for protection from creditors under state or federal proceedings?

Yes ___ No ___ If “Yes”, state the date, court, jurisdiction, cause number, amount of liabilities and amount ofassets.

10. Disciplinary Action: Has the Respondent ever received any disciplinary action, or any pending disciplinary action, from any regulatory bodies or professional organizations? If “Yes”, state the name of the regulatory body or professional organization, date and reason for disciplinary or impending disciplinary action.

11. Previous Contracts: a. Has the Respondent ever failed to complete any contract awarded?

Yes ___ No ___ If “Yes”, state the name of the organization contracted with, services contracted, date, contract amount and reason for failing to complete the contract.

b. Has any officer or partner proposed for this assignment ever been an officer or partner of some other organization that failed to complete a contract? Yes ___ No ___ If “Yes”, state the name of the individual, organization contracted with, services contracted, date, contract amount and reason for failing to complete the contract.

c. Has any officer or partner proposed for this assignment ever failed to complete a contract handled in his or her own name? Yes ___ No ___ If “Yes”, state the name of the individual, organization contracted with, services contracted, date, contract amount and reason for failing to complete the contract.

12. References: Provide three (3) references that Respondent has provided services to within the past three (3) years.

The contact person named should be familiar with the day-to-day management of the Respondent and be willing to respond to questions regarding the type, level, and quality of service provided.

Reference No. 1:

Firm/Company Name ________________________________________________________

Contact Person: ________________________________ Title: _______________________

Address: __________________________________________________________________

City: ______________________________State: _______________Zip Code: ___________

Email: ____________________________________________________________________

Phone: __________________________

Date and Type of Service(s) Provided: ___________________________________________

Reference No. 2:

Firm/Company Name ________________________________________________________

Contact Person: ________________________________ Title: _______________________

Address: __________________________________________________________________

City: ______________________________State: _______________Zip Code: ___________

Email: ____________________________________________________________________

Phone: __________________________

Date and Type of Service(s) Provided: ___________________________________________

Reference No. 3

Firm/Company Name ________________________________________________________

Contact Person: ________________________________ Title: _______________________

Address: __________________________________________________________________

City: ______________________________State: _______________Zip Code: ___________

Email: ____________________________________________________________________

Phone: __________________________

Date and Type of Service(s) Provided: ___________________________________________