CRFQ DOT2600000031 Exhibit D Contractor Qualification Statement.docx

CONTRACTOR QUALIFICATION STATEMENT – Exhibit D

Qualification Statement Submitted For (Insert Project Name):

Type of Work to be Performed on this Project:

ORGANIZATION:

Type of Entity:

Name of Principal, Owners or Partners:

NOTE: If “yes,” list name, type of entity and names of principal, owners or partners.

Provide a brief description of the general type of construction the firm performs.

Key Personnel:

Please provide information regarding the experience and skill of the bidder’s key personnel (Project Manager, Superintendent, Foreman, etc.) for the project. Attach additional information, if required.

RELEVANT PROJECT EXPERIENCE:

If you have completed school construction work or similar construction, or completed work on SBA projects, provide a list of projects with individual references that can verify the quality of your work, your ability to construct within budget, and your ability to work within the proposed schedule.

NOTE: Attach additional information, if necessary. Marked as Attachment ___.

Please list all major construction projects (schools or other projects) your organization has in progress providing the name of Project, Owner, Architect, contract amount, Bonding Company, Insurance Carrier, percentage complete and scheduled completion date.

Marked as Attachment ___.

Please list major projects (schools or other projects) your organization has completed in the past five years, giving the name of project, Owner, Architect, contract amount, Bonding Company, date of completion and percentage of the cost of the work performed with your own forces. Note whether or not each project was completed on schedule.

Marked as Attachment ___.

REGULATORY COMPLIANCE:

At any time during the past five years, has your firm, or any of its owners or officers been found in violation or in default in any of the following categories:

NOTE: If answered “Yes,” attach detailed explanation. Marked as Attachment ___.

CLAIMS AND SUITS:

NOTE: If answered “Yes,” attach detailed explanation. Marked as Attachment ___.

Has your organization ever failed to complete any Construction work Yes ____ No ____ it has been awarded?

Within the last five years, has any officer or principal of your Yes ____ No ____ organization ever been an officer or principal of another organization when it failed to complete a construction contract?

Has there been in the last ten (10) years, or is there now pending or Yes ____ No ____ threatened, any litigation, arbitration, investigation, or governmental or regulatory proceeding involving claims in excess of $100,000 or requesting a declaratory judgment or injunctive relief with respect to the construction or operation of any building which your firm, its principals, predecessors or affiliates constructed?

Is there any potential claim, demand, litigation, arbitration, Yes ____ No ____ investigation, governmental proceeding or regulatory proceeding involving your firm, or its principals, predecessors or affiliates?

In addition to the litigation, arbitration, investigation or governmental Yes ____ No ____ or regulatory proceeding referred to in the preceding paragraphs, is there any litigation, arbitration, investigation or governmental or regulatory proceeding now pending or threatened to which your firm is or may be a party, or are you aware of any potential claim or demand, which might otherwise affect the capacity of your firm to perform with respect to your involvement with the School Building Authority of West Virginia, whether or not it concerns other work which you have undertaken?

At any time during the past five (5) years has your firm, or any of its Yes ____ No ____ owners or officers, been debarred or otherwise deemed ineligible to bid on or be awarded a public works contract or perform work as a subcontractor on a public works contract, under the laws of the federal government, state, county or municipal authority?

NOTE: If answered “Yes,” attach detailed explanation. Marked as Attachment ___.

At any time during the last five (5) years has your firm, or any of its Yes ____ No ____ owners or officers, been convicted of a crime relating to the awarding of a contract for a public works construction project, or the bidding or performance of a public works project?

Is there any person owing ten (10) percent or more of this company, or Yes ____ No ____ officer of the company, that is currently, or at the time of the bid, on the Worker’s Compensation Employer Violator System?

BANKRUPTCY:

Has your firm, its principals, predecessors, or affiliates been the Yes ____ No ____ subject of any proceeding under the federal bankruptcy laws or any other proceeding under state or federal law in which a court or government agency has assumed jurisdiction over any of the assets or business of your firm, its principals, predecessors or affiliates?

If so, please identify the proceedings, the court or governmental body and the date such jurisdiction was assumed in an attachment.

REFERENCES:

Please list below trade references:

Please list below bank references:

Please list below completed project owner references:

AFFIRMATION, SIGNATURE, AND NOTARY:

By signing this form, the bidder’s authorized signer affirms and acknowledges under penalty of law for false swearing (W.Va. Code §61-5-3) that the undersigned certified under oath that the information provided herein is true and sufficiently complete so as not to be misleading.

WITNESS THE FOLLOWING SIGNATURE:

Name of Organization: _________________________________________________________________

Name: _________________________________ Title: ________________________________________

Authorized Signature: _________________________________________ Date: ____________________

State of: ____________________________________

County of: __________________________________, to-wit;

Taken, subscribed, and sworn to before me this ____ day of ______________________________, 20___.

My Commission expires: ___________________________, 20___.

AFFIX SEAL HERE NOTARY PUBLIC: ____________________________