ADV_Bidder's Qualifications Form.doc

INSTRUCTIONS: Answer all questions on this form inserting "none" or "not applicable" where appropriate. If more space is required attach additional sheets. Return the signed, dated and completed form with the bid to the address shown in the invitation for bids on or before the time set for bid opening. The prospective bidder shall provide any additional information requested by the Government during evaluation of the bids.

If the prospective bidder is a joint venture or general partnership, a separate Bidder's Qualifications form shall be provided individually for each joint venture participant or partner.

1. Project Name:

Natchez Trace Parkway

Solicitation No.: DTFH71-11-B-00010

2. Name and address of business:

Contractor Tax ID

Company Name

Contractor DUNS Number

Street

City

State

Zip Code

County

Telephone Number (Include Area Code)

Fax Number (Include Area Code)

E-mail Address

Web site address

3. a. Type of organization (check appropriate box):

□ Individual

□ Non-profit organization

□ Corporation

□ Partnership

□ Joint Venture

State

Incorporated in: __________

□ Limited Liability Company (LLC)

If a foreign entity:

□ Individual

□ Non-profit organization

□ Corporation

b. Size of Business Concern (check appropriate boxes):

□ Large Business Concern

□ Small Business Concern

□ Emerging Small Business

Concern

□ Small Disadvantaged

Business Concern

□ Women-Owned Small

Business Concern

□ SBA 8(a) Certified SDBC

□ HUBZone Small Business

Concern

□ Veteran-owned Small

Business Concern

□ Service-Disabled Veteran Owned Small Business Concern

{See FAR Clauses 52.219-1 and 52.219-19 for small business definitions.}

4. If a joint venture or general partnership:

a. Provide the name under which the project will be bid, the home office address, and name of the principal who will represent the company with regard to this project if different from "1." above.

TAX ID:

Principal

DUNS #

Business Name

Street

b. Provide the name and home office addresses of each of the joint venture partners; indicate which partner is the sponsoring partner. Attach a separate sheet for additional partners.

Sponsoring Partner

Other Partner

Street

Street

5. Date business established: _________________________

6. Name of succeeded business, if any: _________________________

7. How many years have you been in business as:

a. General contractor: _______ Years.

b. Subcontractor: _______ Years.

8. a. Furnish the following information concerning the owner, partners, officers and directors:

Business Experience

b. Attach resumes of these key personnel as well as the on-site project manager(s) and superintendent(s), and specifically identify the following:

-Present position, responsibility, and length of employment.

-Amount and type of construction experience.

-Amount and type of highway construction experience, including position, responsibility, and a brief project description of each period of employment.

-Formal education and training, professional or technical registrations or licenses.

9. a. Active Contracts (Attach additional sheets if necessary) Must be filled in Contact Person, phone numbers and e-mail addresses.

Contact Person, Telephone Number, &

E-mail address Scope of Work Performed

By Your Company

b. Are there any unresolved claims or lawsuits associated with these projects? If so, state the amount in dispute, parties involved, nature and circumstances of the dispute, and status of the matter on a separate sheet.

10. a. List at least five of the largest jobs you have completed in the last five years which are similar in project work scope to this project.

(Attach additional sheets if necessary) Must be filled in Contact Person, phone numbers and e-mail addresses.

b. Are there any unresolved claims or lawsuits associated with these projects? If so, state the amount in dispute, parties involved, nature and circumstances of the dispute, and status of the matter on a separate sheet.

11. Termination:

a. Has your firm ever had a contract terminated for any reason? ________

b. If the answer is yes, identify the project and owner for each termination, and explain the circumstances surrounding each termination. Attach additional sheet if necessary.

12. Debarment and Suspension:

a. Has your firm or any of the principals been suspended or debarred from bidding by any agency? ______

b. If the answer is yes, identify the agency by which debarred or suspended, and date of reinstatement. Attach additional sheet if necessary.

13. What types of work do you perform as general contractor?

14. What types of work do you perform as subcontractor?

15. What types of work do you generally subcontract?

16. Affidavit:

Certification: For the purpose of establishing construction capabilities, we furnish the above as a true and correct statement of our construction experience and further certify that all other statements are true and correct.

By (Signature of Authorized Official)

Date

Title