Contractor's_Qualification_Form.pdf

CONTRACTOR’S QUALIFICATION FORM

Your Bid Will Not Be Processed If Incomplete

SECTION I - IDENTIFICATION

1. Identification of Applicant Firm

A.

Exact Legal Name of Applicant Firm DUNS #

B.

Street Address City State Zip Code

C.

(Mailing Address, if different from above)

D. Primary Company Telephone No. E-mail.

E. Applicant Firm's Contact Person for Public Works Office follow-up:

Print or Type Name Position Telephone Number

F. Has the Applicant Firm changed its address or has the Firm or its Owner(s) operated under any other name(s) including other DBAs in the past five years? If yes, explain fully on a separate sheet of paper.

☐ No ☐ Yes

G. Type of business organization:

YEAR organization established: NUMBER of current full time employees:

☐ Sole Proprietor ☐ Corporation – [Date and State of Incorporation

☐ Limited Partnership ☐ General Partnership

[Date and State of Partnership filing

☐ Limited Liability Company ☐ Limited Liability Partnership

[Date and State of filing

☐ Other (describe)

Type of service(s) to be provided to the City of Wheat Ridge.

☐ General Contractor ☐ Concrete Flatwork

☐ Storm Sewer ☐ Concrete Structures

☐ Traffic Signals ☐ Slurry Seal

☐ Grading ☐ Fog Seal

☐ Asphalt Paving ☐ Crack Sealing

☐ Concrete Paving ☐ Landscaping

☐ Signing ☐ Striping

☐ Traffic Control ☐ Other (describe)

SECTION II - OWNERSHIP/MANAGEMENT, PROJECT MANAGEMENT,

SUPERVISORS, AND RELATED ENTITIES

1. Owners

List Owners of Applicant Firm.

Full Legal Name Title Years of Related Experience

% Of Ownership

[Use additional sheets if necessary]

2. Project Management Team, Supervisors and Employees Who Will Be Working Directly On the Project(s).

List the full names of the primary employees of the proposed Project Team.

Full Legal Name Present Position Years of Related

Experience

% of Time Devoted to

Project

Professional Licenses

[Use additional sheets if necessary]

3. Resume

Attach resumes of the Project Management Team showing the last five years of employment in this field.

Resumes must be comprehensive and include of Firms worked for and dates of employment. (RESUMES are not required from Materials Suppliers (Vendors).

4. Contractor’s License(s)

The awarded Contractor must obtain or have a current City of Wheat Ridge Municipal Contractor’s License within 7 days of Council approval of bid award.

SECTION III - CONTRACTING HISTORY

1. Contracting History

A. List the applicant Firm’s six largest contracts in the last three years.

1. Company Name Contact Name

Street Address

City State Zip Code

Phone No: E-mail:

Contract Name & Number

Contract Amount Start/Completion Dates

Description of Work

Prime or Subcontractor

2. Company Name Contact Name

Street Address

City State Zip Code

Phone No: E-mail:

Contract Name & Number

3. Company Name Contact Name

Street Address

City State Zip Code

Phone No: E-mail:

Contract Name & Number

SECTION III - CONTRACTING HISTORY – (Continued)

4. Company Name Contact Name

Street Address

City State Zip Code

Phone No: E-mail:

Contract Name & Number

5. Company Name Contact Name

Street Address

City State Zip Code

Phone No: E-mail:

Contract Name & Number

6. Company Name Contact Name

Street Address

City State Zip Code

Phone No: E-mail:

Contract Name & Number

SECTION III - CONTRACTING HISTORY – (Continued)

In the past five years has the Applicant Firm or any Affiliate been the subject of any of the following actions?

A. Been suspended, debarred, disqualified, or otherwise declared ineligible to bid?

☐ No ☐ Yes

B. Failed to complete a contract for a commercial, private owner or Government agency?

☐ No ☐ Yes

C. Been denied a low-bid contract in spite of being the low bidder?

☐ No ☐ Yes

D. Had a contract terminated for any reason, including default?

☐ No ☐ Yes

E. Had liquidated damages assessed against it during or after completion of a contract?

☐ No ☐ Yes

If “Yes” to Sections IV, V or VI, provide details including a brief summary of cause(s) of action, indicate if Applicant Firm, Owner or Affiliate Firms were plaintiffs (P) or defendants (D); define charges explicitly, by what authority, court or jurisdiction, etc. Complete details are required!

NOTE: For Sections IV and V below, the definition of an "investigation" includes: an appearance before a grand jury by representatives of the Firm; any oral or written inquiry or review of the Firm’s documents by a governmental or law enforcement agency or investigative agency; or questioning of employees concerning the general operation or a specific project or activities of the Firm

SECTION IV - CIVIL ACTIONS

1. Violations Of Civil Law In the past five years has Applicant Firm, any of its Owners, or any Affiliate been the subject of an investigation of any alleged violation of a civil antitrust law, or other federal, state or local civil law?

☐ No ☐ Yes

2. Lawsuits With Public Agencies At the present time is, or during the past five years has the Applicant Firm, any of its Owners, or any Affiliate been a plaintiff or defendant in any lawsuit regarding services or goods provided to the City of Wheat Ridge or to a public agency?

☐ No ☐ Yes

3. Bankruptcy During the past five years, has the Applicant Firm or any Affiliate filed for bankruptcy or reorganization under the bankruptcy laws?

☐ No ☐ Yes

4. Judgments, Liens And Claims During the past five years, has the Applicant Firm been the subject of a judgment, lien or claim of $10,000 or more by a subcontractor or supplier?

☐ No ☐ Yes

5. Tax Liens During the past five years, has the Applicant Firm been the subject of a tax lien by federal, state or any other tax authority?

☐ No ☐ Yes

SECTION V - COMPLIANCE WITH LAWS AND OTHER REGULATIONS

1. Criminal

In the past five years has the Applicant Firm, any of its Owners, or Affiliates:

A. Been the subject of an investigation involving any alleged violation of criminal law?

☐ No ☐ Yes

B. Been arrested, indicted or named as an unindicted co-conspirator in any indictment or other accusatory instrument?

☐ No ☐ Yes

C. Been convicted, after trial or by plea, of any felony under state or federal law?

☐ No ☐ Yes

D. Been convicted of any misdemeanor involving business-related crimes?

☐ No ☐ Yes

E. Entered a plea of nolo contendere to a charge of embezzlement, theft, forgery, bribery, falsification or destruction of records, receiving stolen property, or a violation of any antitrust laws?

☐ No ☐ Yes

F. Entered into a consent decree?

☐ No ☐ Yes

G. Been granted immunity from prosecution for any business-related conduct constituting a crime under state or federal law?

☐ No ☐ Yes

H. Taken the Fifth Amendment in testimony on any business-related crime?

☐ No ☐ Yes

I. Paid a fine or settlement to resolve any criminal or civil violations or allegations involving a business activity?

☐ No ☐ Yes

J. Do any Owners in Applicant Firm have any felony charges pending against them that were filed either before, during, or after their employment with the Applicant Firm?

☐ No ☐ Yes

1. Regulatory Compliance

In the past five years, has Applicant Firm, any of its Owners, or Affiliates been cited for:

A. A violation of any labor law or regulation, including prevailing wage rates and fair labor practices?

☐ No ☐ Yes

B. An OSHA violation?

☐ No ☐ Yes

C. A violation of federal, state or local environmental laws or regulations?

☐ No ☐ Yes

D. Any other administrative, statutory or regulatory violations?

☐ No ☐ Yes

SECTION VI - ETHICS

1. False Statements, Bribes, Collusion

In the past five years has the Applicant Firm, any of its Owners, or Affiliates:

A. Filed with a government body (including City of Wheat Ridge) or submitted to a government employee (including City of Wheat Ridge employee) any form of document known by the Applicant Firm, any of its Owners, or by the person submitting the document, to contain false information?

☐ No ☐ Yes

B. Created or maintained false business records?

☐ No ☐ Yes

C. Given, or offered to give, money or any other benefit to a public official or employee with intent to influence that person regarding any of their official acts, duties or decisions?

☐ No ☐ Yes

D. Given, or offered to give, money or other benefit to an official or employee of a private business with intent to induce that official or employee to engage in unethical or illegal business activities (including but not limited to improper gratuities, and/or violations of lobbying regulations)?

E. Agreed with another to bid below prevailing market rate?

F. Agreed with another to submit identical or complimentary bids or otherwise not to bid competitively?

☐ No ☐ Yes

G. Agreed with another not to submit competitive bids in another's territory established either by geography or customers?

☐ No ☐ Yes

H. Agreed with another to take turns in obtaining contracts by pre-determining which Firm shall submit the lowest bid?

☐ No ☐ Yes

2. Conflict Of Interest

A. Does the Applicant Firm, any of its Owners or Project Team Members have any existing relationships that could be construed as either personal or organizational conflicts of interest, or which would give rise to a conflict if Applicant Firm should be a recipient of a contract with the City of Wheat Ridge?

☐ No ☐ Yes

B. Has any Owner or Project Team member of Applicant Firm ever (if yes explain fully):

1. Been an employee of the City of Wheat Ridge, or served as a Member of Wheat Ridge City Council?

☐ No ☐ Yes

2. Been related by blood or marriage to a City of Wheat Ridge employee or Council Member?

☐ No ☐ Yes

SECTION VII - ADDITIONAL DOCUMENTATION REQUIRED

Additional document copies to be submitted with this application:

Letter of Reference from your Firm’s Surety, which states current available aggregate and single project bonding capacity (This Application will not be processed without this letter)

Certification of all IMSA certified personnel, if applying for traffic signal project(s). A minimum of two full time employees must be certified at Level II or higher.