Chicago Concrete Surfaces HTL Form Revised.docx

PROFESSIONAL SERVICES QUALIFICATIONS

SOS HTL FORM

PART I: Project SOS Bulletin Number: Project Number: Project Description:

PART II: Firm Information CDB Prequalification: Yes / No If yes, Prequalification Number: Expiration Date:

Firm Name:

Address: Branch Office Address:

Phone Number: Branch Office Phone Number:

Fax Numbers: Branch Office Fax Number:

For Joint Venture (“JV”), include information for all members, design discipline of each member and percentage (of total design team) of services of each member.

Contact Person: Email Address:

Approximate distance to project location: (Miles) Enter “NA” if location has not been determined.

CMS Certifications (select only one): |_| MBE |_| WBE |_| VBE |_| N/A CMS Certification Expiration:

PART III: Certifications and Disclosures IPG (Illinois Procurement Gateway) Registered:

IPG Number: IPG# Expiration Date: Forms B Attached |_|

If not registered with the IPG: Forms A attached |_|

PART IV: Project Approach

Explain in moderate detail the approach that will be taken to accomplish this project as advertised.

PART V: Relevant Project Scope Experience

(On completed projects current or within the past 10 years, limit to 8 projects for the submitting firm and 4 for each consultant)

Detailed Description of Services Owners Name & Address Prime Contact – Phone/Fax/Email (Consultants, Identify the Prime A/E) Completion Date (estimate if not complete).

Total Project Cost

PART VI: Team Personnel

Team personnel, by discipline, to be designated for this project including all consultants. Indicate personnel licensed in Illinois. Submit a resume for each individual listed below. DO NOT include clerical and/or support staff.

PART VII: Consultants

Please list the consultants that will be performing any portion of basic design services for this project. Any firm providing architectural, engineering, asbestos abatement design services or land surveying must be prequalified with CDB. Consultants that are not providing the aforementioned regulated services do not have to be prequalified with CDB, but should be registered with CDB as a sub-consultant. These may include cost consultants, food service consultants, etc. The firms listed below are considered first tier consultants and shall hold a contract directly with the firm submitting this HTL Form.

· Failure of the consultants, providing regulated design services, to be prequalified, will result in rejection of the Prime A/E’s submittal(s).

(yes or no)

Date

PART VIII: Team Personnel Resumes

TEAM PERSONNEL RESUMES SHALL INCLUDE AND BE IN THE BELOW FORMAT:

(a) Name and Title

(b) Project Assignment

(c) Firm Name and Complete Office Address for this Individual

(d) Years of Experience with this Firm (with other firms)

(e) Education: Institution/Field of Study/Degree/Year Obtained

(f) Active Licenses/Certifications/Type/Year

(g) Specific Relevant Project Experience Including Individual’s Level of Responsibility

Please attach all resumes to this HTL Form.

PART IX: Signature

Form must be signed by the Firm’s President, Vice President, Partner or Sole Owner, Joint Venture Designee or any other person authorized to execute business on the behalf of the firm/JV.

Signature: Title:

Printed Name: Date:

Evaluation Guidelines and Instructions

Project Approach (Part IV)

Relevant Experience (Part V)

Team Personnel and Subconsultants (Part VI, VII, and VIII)

Location (proximity) (Part II)

Workload/Capacity of Firm (Part V)

PURPOSE

The Office of the Illinois Secretary of State (SOS) and state-supported institutions of higher education use this form to obtain information from Architect/Engineer (“A/E”) firms about their professional qualifications. The SOS and supported agencies select firms for A/E contracts on the basis of professional qualifications as required by Illinois Compiled Statutes; Illinois Procurement Code, 30 ILCS 500 and Architectural, Engineering and Land Surveying Qualifications Based Selection Act, 30 ILCS 535.

It is the policy of State agencies of this State to publicly announce all requirements for architectural, engineering, and land surveying services to procure these services on the basis of demonstrated competence and qualifications, to negotiate contracts at fair and reasonable prices, and to authorize the Department of Professional Regulation to enforce the provisions of Section 65 of the Architectural, Engineering, and Land Surveying Qualifications Based Selection Act.

The information used to evaluate firms is from this form and other sources, including performance evaluations, any additional data requested by the agency, and interviews with the most highly qualified firms and their references.

DEFINITIONS

Architect, Engineer and Land Surveying Services: Defined in Section 5 of the Illinois Architecture Practice Act of 1989; Section 4 of the Professional Engineering Practice Act of 1989 or Section 5 of the Structural Engineering Practice Act of 1989; and Section 5 of the Illinois Professional Land Surveyor Act of 1989, respectively.

Branch Office: A geographically distinct place of business or subsidiary office of a firm that has a key role on the team.

Discipline: Primary technical capabilities of key personnel, as evidenced by academic degree, professional registration, certification, and/or extensive experience.

Firm: Any individual, sole proprietorship, firm, partnership, corporation, association, or other legal entity permitted by law to practice the profession of architecture, engineering, or land surveying.

Key Personnel: Individuals who will have major contract responsibilities and/or provide unusual or unique expertise.

Project: Any capital improvement project or any design, study, plan, survey, or new or existing program activity of State agency, including development of new or existing programs that require architectural, engineering, or land surveying services.

Agency: Any department, commission, council, board, bureau, committee, institution, agency, university, government, corporation, authority, or other establishment or official of this State.

FORM COMPLETION DIRECTIONS

General Requirements The HTL form may not be altered (e.g. inserting company logos, editing text outside the fillable fields, rearranging form parts, changing fonts or text color, etc.) from its original state. Forms submitted with alterations may be rejected.

Part I: Project Basic project information which is obtained from the Professional Services Bulletin in which the project was advertised.

Part II: Firm Information CDB Prequalification The firm applying for the project is required to be prequalified through CDB. Enter the firm’s prequalification number and expiration date. Additional prequalification information is available here:

https://www2.illinois.gov/cdb/business/Pages/Prequalification.aspx Basic Firm Information The street address of the parent or branch office must correlate to the information CDB has on file for the prequalification number provided. Brach offices are required to be independently prequalified separately from the parent office.

Distance to Project Provide an approximate distance from the firm office to the project site. Enter “N/A: if the project location is not determined.

CMS Certifications If the prime firm is a CMS Certified Minority Business Enterprise (MBE), Woman Business Enterprise (WBE), or Veteran Business Enterprise (VBE), check the appropriate box. Only one certification may be selected. Provide the expiration of the CMS Certification.

Part III: Certifications and Disclosures Attach a copy of the State of Illinois Forms A or B. Please make sure the entirety of each document is filled out before attaching.

If attaching Forms A, you must include the Secretary of State’s Certificate of Good Standing and State Board of Elections Certificate of Registration.

If attaching Forms B, include the firm’s Illinois Procurement Gateway (IPG) number and expiration date.

Part IV: Project Approach Describe in moderate detail the approach that will be taken to accomplish this project as advertised.

Part V: Relevant Project Scope Experience Enter the firm name of the Prime or Consultant, total project cost and the completion date (estimated if not complete).

On the right, enter the Owner’s name and contact information. If this entry is for consultant experience, enter the Prime A/E’s name and contact information.

Please keep all text within the existing boundaries of the “Brief Project Description” and “Level of Responsibility& Detailed Description of Services” form fields. If text overruns the boundaries, it will not print properly and portions will not be visible for review in paper form.

You may copy and paste additional rows as needed to provide additional Relevant Project Experience.

Part VI: Team Personnel List the number of personnel assigned to this project according to their discipline. Also provide the number of which are licensed to practice in Illinois. Personnel that does not fit into one of the provided disciplines may be listed in “Other.” Please provide a description of their discipline.

Part VII: Consultants Please list the consultants that will be performing any portion of basic design services for this project.

The percentages entered must correlate to the percentages entered in Part VII.

Provide the work scope that the consultant will provide in the General Scope of Services Field.

If the consultant is a CMS certified MBE/WBE/VBE, indicate accordingly. Provide their CMS certification expiration date. Expired CMS certification will not count toward the MBE/WBE/VBE goals, if required. Enter ”N/A” if the firm is not CMS certified MBE/WBE/VBE.

Part VIII: Team Personnel Resumes A Team Personnel Resume Page shall be included for each member of the team.

Enter the Prime/Joint Venture and Consultant Team Members.

Any contract awarded in response to this submittal is conditioned on the qualifications of the firm and the project team individuals as stated below. Therefore, the team listed below shall be assigned to this project if a contract is awarded to the submitting firm.

You may copy and paste additional rows as needed if the number of team members exceeds the entry spaces of the page.

Entry headings are self-explanatory.

Part IX: Signature This Part will be the last part of the HTL that is addressed. All other parts before and after this part must be filled out prior to signing the HTL.

The HTL must be signed by the Firm’s President, Vice President, Partner or Sole Owner, Joint Venture Designee or any other person authorized to execute business for the firm/JV.

SUBMISSION

The form of the submittal package is at the discretion of the submitting firm. A letter of introduction is permitted but not necessary. The submitted package should be bound (stapled, in a notebook, presentation folder, etc.) but does not need to be in a “Book” form. Photographs are allowed.

Electronic submissions must be done through BidBuy (https://www.bidbuy.illinois.gov/bso/view/login/login.xhtml).

Hard copies must be submitted to:

The Office of the Illinois Secretary of State Department of Budget and Fiscal Management Room 116, Michael J. Howlett Building 501 S. Second Street Springfield, IL 62756 Attn: Katherine Tople

QUESTIONS?

If you have any questions about completing the form, please email ktople@ilsos.gov or call 217-782-7198.

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