Document 420 - Statement of Qualifications.pdf

Document 00420 Rev. 01/30/2019 1

For: USNH Event # 212027989 CM Services - KSC Student Center, Mabel Brown Room Theatrical and House Lighting Upgrades

KEENE STATE COLLEGE

KEENE, NEW HAMPSHIRE

DOCUMENT 00420 - STATEMENT OF QUALIFICATIONS

1. Business Name: ____________________________________________________________________________

2. Principal Address: ___________________________________________________________________________

3. Phone Number of Principal Place of Business: ____________________________________________________

4. Fax Number of Principal Place of Business: ______________________________________________________

5. List names, business addresses, phone numbers and email addresses of the company’s chief executive officer (CEO), chief financial officer (CFO) and, if the firm is a partnership, LLC or PLLC, other principals as appropriate.

CEO

Name:_______________________________________________ Phone:_____________________________

Address:__________________________________________________________________________________

E-mail address:_____________________________________________________________________________

CFO

Name:_______________________________________________ Phone:_____________________________

Address:__________________________________________________________________________________

E-mail address:_____________________________________________________________________________

Other Principals

6. Project manager or other contact person:

E-mail address:_____________________________________________________________________________

7. Does the firm or any owner, sales/service representative, or employee, have a personal relationship with any USNH employee

(includes all campus locations) (student relationships are not considered)? Yes No If yes, provide details: __________________________________________________________________________

8. Registration with the NH Secretary of State (http://www.sos.nh.gov/corporate/index.html):

New Hampshire business entity – Attach a current certificate of existence (ref. NH-RSA 293-A:1.28).

Document 00420 Rev. 03/03/2021 2

Non-New Hampshire business entity – Attach a current certificate of authority to transact business in the State of New Hampshire. Note that NH-RSA 293-A:15.01 prohibits foreign business entities from transacting business in the State of New Hampshire, without first obtaining a certificate of authority from the secretary of state.

9. Year Organized: ________

10. Organized in State of: ________________________

11. Number of years engaged in this business under the present business name: _____________________________

If now or formerly in business under another name, supply details:

12. Number of full-time employees: __________

13. If a contractor, what categories of work do you perform with your own forces?

14. List your major equipment available. (Required of GCs and design/build only)

15. Total dollar value in projects your firm completed in the last five years (note: for GCs, CMs and design/build projects cite total construction value; for professional firms, cite total fees billed):

2025_________; 2024_________; 2023_________; 2022_________; 2021__________

16. List all major current projects (>$500,000). Include name of project, owner, contract amount, percent complete, and scheduled completion date. Attach separate sheet if necessary. (For DBB projects only, all others see Submission Requirements)

17. List any projects completed for the University System of New Hampshire within the last ten years. Include campus, project, final contract (construction) or billing (professional services) amount, completion date, and name of owner’s representative. Attach separate sheet if necessary.

18. List the key personnel of this business proposed to, or likely to, work on this project including Project Manager, Site

Superintendent, Field Engineer, Safety Manager, and other prominent field crew and office personnel. Attach brief resumes of all listed personnel, complete with qualifications and construction experience. (For design/bid/build projects only, all others see Submission Requirements)

Document 00420 Rev. 03/03/2021 3

Name Position

______________________________________________________, Project Manager

______________________________________________________, Site Superintendent

______________________________________________________, Field Engineer

______________________________________________________, Safety Manager

19. Has this business ever defaulted on a contract or failed to complete any project awarded to it?

Yes No If so, state the circumstances in an attachment.

20. Has any surety which issued a performance bond on behalf of this business ever completed work in its own name or financed such completion?

Yes No If so, state the circumstances in an attachment.

21. Has this business or any principal or officer of this business ever been disqualified or precluded from bidding?

22. Has this business ever had liquidated damages or other contract penalties assessed to it?

Yes No If so, state the circumstances in an attachment.

23. Are there any civil or criminal judgments, claims, arbitration proceedings, or suits pending or outstanding against this business or any of its principals or officers?

24. Has this business filed any lawsuits or requested arbitration with regard to construction contracts within the last five years?

25. Name of submitting contractor’s Surety (Important Note: Surety must be authorized to transact business in the State of New

Hampshire and must appear in the U.S. Treasury Department’s most current Circular 570, as amended):

Attach a letter from the above-listed Surety containing a statement indicating the prospective Contractor’s total bonding capacity, current bonding liability and currently available bonding capacity.

26. No financial statements are required to be submitted with your qualifications package. However, prior to an award, USNH may request financial statements from your firm, credit reports and letters from your bank and suppliers. If requested, and your firm does not comply with the request, this may be grounds for rejection of your bid.

Financial statements are considered confidential by the USNH Purchasing and Contract Services Office and, as such, will be destroyed when said documents are no longer required.

FORM CONTINUES ON NEXT PAGE

Document 00420 Rev. 03/03/2021 4

27. DEBARMENT: The firm certifies, by submitting this Statement of Qualifications, that neither it nor its principals are presently debarred, suspended, proposed for debarment, have been declared ineligible, or voluntarily excluded from participation in this transaction (contract) by any governmental department or agency. If the firm cannot certify this statement, attach a written explanation for review by the University System of New Hampshire.

I hereby certify the above information to be correct and authorize the University System of New Hampshire to investigate all facts contained therein, including facility visitation.

Name of Organization

By: ______________________________________________

Title: ____________________________________________

Date: ____________________________________________

State of _________________

County of _______________

_____________________________________________, being duly sworn, deposes and says that he/she is

___________________________________________ of (Title)

(Name of Organization) and that the answers to the foregoing questions and all statements contained therein are true and correct.

Sworn to before me on this date: _________________________________________________________________

Notary Public/Justice of the Peace

My commission expires: _____________________________.

END OF DOCUMENT