Attachment L - Contractor Qualification Statement Form.pdf

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KING GEORGE COUNTY

CONTRACTOR’S QUALIFICATION STATEMENT

Required in advance of consideration of acceptance of bid.

The undersigned certifies under oath the truth and correctness of all statements and of all answers to questions made hereinafter.

SUBMITTED TO:

Purchasing Specialist

KING GEORGE COUNTY

10459 Courthouse Dr., Suite 200

King George, Virginia 22485

(540) 775-3177

SUBMITTED BY:

Company Name

Owner/President’s Name

Address

City, State Zip

Corporation

Partnership

Individual

Joint Venture _________

Other

(Note: Attach separate sheets as required)

1.0 How many years has your organization been in business as a general contractor?

2.0 How many years has your organization been in business under its present business name?

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3.0 If a corporation, please answer the following:

3.1. Date of incorporation:

3.2. State of Incorporation:

3.3. President’s Name:

3.4. Vice-President’s Name(s):

3.5. Secretary or Clerk’s name:

3.6. Treasurer’s name:

4.0 If individual or partnership, answer the following:

4.1. Date of Organization:

4.2. Name and address of all partners.

(State whether general or limited partnership):

5.0 If other than corporation or partnership, describe organization and name principals:

6.0 We normally perform % of the work with our own forces. List trades below:

7.0 Have you ever failed to complete any work awarded to you? If so, note when, where, and why:

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8.0 Are you presently involved in any litigation or arbitration over existing contracts or work? If so, note when, where and why:

9.0 Has any officer or partner of your organization ever been an officer or partner of another organization that failed to complete a construction contract? If so, state circumstances:

10.0 List name of project, owner, architect, contract amount, percent complete and scheduled completion of all the major construction projects (bid price of $30,000 or more) your organization has in process on this date:

11.0 List the name of project, owner, architect, contract amount, date of completion, percent of work with own forces of all the major projects (bid price of $30,000 or more) similar in nature to this project your organization has completed in the past ten years:

12.0 Has your organization received a serious, repeated, or willful citation from OSHA, either federal or state or from other safety agencies in the past five years? If so, note when, where, and results of inspection or investigation:

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13.0 List the construction experience of the principal individuals of your organization:

14.0 List states and categories in which your organization is legally qualified to do business:

15.0 Trade References:

16.0 Bank References:

17.0 Name of Bonding Company and name and address of agent:

King George County

Ralph Bunche Maintenance Building Foundation

And Concrete Pilaster Remediation IFB 05082012-1400

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18.0 (Note: This item shall be only required of the apparent low Bidder if requested by the County.)

Attach Statement of Financial Conditions, including Contractor’s latest regular dated financial statement or balance sheet which must contain the following items:

Current Assets: (Cash, joint venture accounts, accounts receivable, notes receivable, accrued interest on notes, deposits, and materials and prepaid expenses), net fixed assets and other assets.

Current Liabilities: (Accounts payable, notes payable, accrued interest on notes, provision for income taxes, advances received from owners, accrued salaries. accrued payroll taxes), other liabilities, and capital (capital stock, authorized and outstanding share per values, earned surplus).

Date of statement or balance sheet:

Name of firm preparing statement:

19.0 Signed by ________________________________________________________ , of _________________

____________________ , contractors, on this____________ day of ________________ , 20 .

20.0 STATE OF COUNTY OF:

being duly sworn deposes and says that he (she) is the _______________________________________________________ of __________________________

_______________________ contractor(s) and that answers to the foregoing questions and all statements therein contained are true and correct.

Subscribed and sworn before me this day of, 20

Notary Public

My commission expires ___________________________________

END OF SECTION