ESBD_File_345215_RESPONSE FORMS - RFQ 913 - IDIQ Eng Svcs for Small Projects.pdf

RESPONSE FORMS - RFQ #913 - IDIQ Eng Svcs for Small Projects Page 1 of 11

(1) Table of Contents - Respondent Checklist

Please upload as ONE (1) PDF attachment online in iStar; the following REQUIRED information in your official submittal in this order:

Please name your PDF: RFQ_913_YourFirmName.pdf Note: PDF file name is limited to 30 characters

Firm Name: _______________________________________________________________________

Please complete the LSC Forms provided.

Check (X)

TAB

Page Order Description

Only the LSC Forms, Federal and State Forms are provided; “Firm Response” are free form

Firm Response 1 Table of Contents - Respondent Checklist This LSC Form

2 Firm Primary Contact LSC Form

3 Cover Letter – Statement of Interest (RFQ page 11) Firm Response

4 Firm Profile Information (RFQ page 11) Firm Response

Completed (5 Maximum) Higher Education Engineering Services Efforts (RFQ page 11 & 12) Firm Response

Relevant References (3) Higher Education, Public entities preferred (other than LSC projects) LSC Forms

7 Proposed Personnel (RFQ page 12) Firm Response

8 Approach Methodology to MEP Engineering Services (RFQ page 12) Firm Response

Texas Historically Underutilized Business (HUB) and Minority, Women, Veteran Business Enterprise MWVBE Utilization Form and HUB Plan LSC Forms

10 Subcontractor(s) (RFQ page 12) Firm Response

(Acknowledge Only by including with submittal, do not complete)

LSC-HSP PAR SDD 2017 7.10.17

(include Blank Form if firm agrees to provide after award for HUB participation monitoring on a regular basis)

LSC Form (available download from LSC-iStar Vendor Portal)

12 Exclusions and/or Substitutions LSC Form

Felony Conviction/Debarment Notice & Clean Air & Water Act Notice (Required-completed and signed) Federal Form

14 Federal Provisions Questionnaire-FEMA (Required completed and signed) Federal Form

15 Conflict of Interest Questionnaire (Required completed and signed)

State Form (available download from LSC-iStar Vendor Portal)

16 Sample Certificate of Insurance Firm

17 Addenda (all pages), if any Provided by LSC, signed by

Respondent

Projects Page 2 of 11

(2) Firm Primary Contact Response Form

Firm Name:

dba: __________________________________________________________________________________(if applicable)

Headquarters Address:

Local Address: ___________________________________________________________________________________________

Phone No.: ______________________________

Webpage: _______________________________

Primary Contact for Clarifications for this RFQ #913 event (please print):

Primary Contact’s Name:

Primary Contact’s Title: ___________________________________________________

Phone Contact’s (if different from above phone no.): _____________________________

Primary Contact’s Email-required (please print):

_________________________________________ @ _________________________.com

(6) Firm’s Most Current Reference

(1 of 3)

Firm Name: _________________________________________________________

Provide three (3) relevant references to the projects requested. These references should include experience with higher education or junior college or public institution within the past three (3) years. Please ensure the contact information is current.

Reference #1:

Company Name: _______________________________________________________________________________________________

Address: _____________________________________________________________________________________________________

Day-to-Day Liaison Contact Name: _________________________________________________________________________________

Phone: ______________________________________________________________________________________________________

Current Email address: _____________________________________________ @ _________________

Brief Description of Program: _____________________________________________________________________________________

Length of Program: _____________________________________________________________________________________________

Length Business Relationship with LSC: ___________________________________________________________________________

Engineer Day-to-Day Liaison Contact Name: __________________________________________________________________

Phone: ______________________________________________________________________________________________________

Current Email address: _____________________________________________ @ _________________

Brief Description of Program: _____________________________________________________________________________________

Length of Program: _____________________________________________________________________________________________

Length Business Relationship with LSC: __________________________________________________________________________

Comments:

RESPONSE FORMS - RFQ #913 - IDIQ Eng Svcs for Small Projects

(2 of 3)

Firm Name: _________________________________________________________

Provide three (3) relevant references to the projects requested. These references should include experience with higher education or junior college or public institution within the past three (3) years. Please ensure the contact information is current.

Reference #1:

Company Name: _______________________________________________________________________________________________

Address: ____________________________________________________________________________________________________

Day-to-Day Liaison Contact Name: ________________________________________________________________________________

Phone: _____________________________________________________________________________________________________

Current Email address: _____________________________________________ @ _________________

Brief Description of Program: _____________________________________________________________________________________

Length of Program: _____________________________________________________________________________________________

Length Business Relationship with LSC: ___________________________________________________________________________

Engineer Day-to-Day Liaison Contact Name: __________________________________________________________________

Phone: _____________________________________________________________________________

Current Email address: _____________________________________________ @ _________________

Brief Description of Program: ___________________________________________________________________________________

Length of Program: ___________________________________________________________________________________________

Length Business Relationship with LSC: _______________________________________________________________________

Comments:

(3 of 3)

Firm Name: _________________________________________________________

Provide three (3) relevant references to the projects requested. These references should include experience with higher education or junior college or public institution within the past three (3) years. Please ensure the contact information is current.

Reference #1:

Company Name: _______________________________________________________________________________________________

Address: _____________________________________________________________________________________________________

Day-to-Day Liaison Contact Name: ________________________________________________________________________________

Phone: ______________________________________________________________________________________________________

Current Email address: _____________________________________________ @ _________________

Brief Description of Program: _____________________________________________________________________________________

Length of Program: _____________________________________________________________________________________________

Length Business Relationship with LSC: ___________________________________________________________________________

Engineer Day-to-Day Liaison Contact Name: __________________________________________________________________

Phone: ______________________________________________________________________________________________________

Current Email address: _____________________________________________ @ _________________

Brief Description of Program: ___________________________________________________________________________________

Length of Program: ___________________________________________________________________________________________

Length Business Relationship with LSC: _______________________________________________________________________

Comments:

Projects Page 6 of 11

(9) TEXAS HISTORICALLY UNDERUTILIZIED BUSINESS (HUB) and

MINORITY, WOMEN, VETERAN BUSINESS ENTERPRISE (MWVBE)

UTILIZATION FORM

Company Name:

I. If your company is a Historically Underutilized Business (HUB) and/or Minority, Women, Veteran

Business Enterprise (MWVBE), then complete Section I and III.

II. If your company is NOT a HUB or MWVBE or if your company plans to utilize HUB or MWVBE sub contractor(s), complete Sections II and III.

III. In Section III, list the subcontractors you plan to utilize to achieve the utilization goal. Attach the certification with each subcontractor in a separate attachment.

Section I: Please check the appropriate group and attach your Certification(s) behind this form in your submittal.

Please state your business utilization goal with your own work force you wish to achieve.

% of our business utilization goal with our own work force

Please state your business utilization goal with other Certified HUB, Minority, Women, and Veteran Business Enterprise (MWVBE).

% of our business utilization goal with other Certified HUB, Minority, Women, and Veteran Business Enterprise

(MWVBE).

☐City of Austin

☐City of Houston

☐Dallas/Fort Worth Minority Supplier

Development Council

☐El Paso Hispanic Chamber of

Commerce

☐Golden Triangle Minority Business

Council

☐Houston Minority Supplier

Development Council

☐South Central Texas Regional

Certification Agency

☐Women’s Business Enterprise National

Council

☐Southwest Minority Supplier

Development Council

☐State of Texas HUB

☐Texas Department of

Transportation

☐Women’s Business Council

Southwest

☐Women’s Business Enterprise

Alliance

☐U. S. Department of Veteran

Affairs

☐National Minority Supplier

Development Council

Projects Page 7 of 11

(9) TEXAS HISTORICALLY UNDERUTILIZIED BUSINESS (HUB) and

MINORITY, WOMEN, VETERAN BUSINESS ENTERPRISE (MWVBE)

UTILIZATION FORM

Section II: ☐ We ARE NOT Certified

% of our business utilization goal with other Certified HUB, Minority, Women, and Veteran Business Enterprise

(MWVBE).

Section III: We Have Sub Contractors

If additional space is required, please attach information in the below format behind this form in your submittal.

Insert certification(s) for each Company after this page

Address

Company

Contact Phone #

Subcontracting

0%

Total Estimated Utilization Goal for proposal:

Date:

Printed Name:

Title:

Signature:

Company Name

Estimated Utilization Total

Projects Page 8 of 11

(9) HUB PLAN

Company’s Certified HUB, Minority, Women, Veteran Business Enterprise (MWVBE) Business Procedures to Establish Utilization Goals, Community Outreach, Designated Supplier Diversity Staff, Tools Used to Report to LSC on Actual Utilization and Overall Company Plan

Insert information here.

(12) Exclusions and/or Substitutions Statement Form

Firm Name: _____________________________________________________________________

This form must be completed and attached to your complete PDF submittal.

________We DO have exclusions and/or substitutions included here for any documents pertaining to the RFQ #913

________We DO NOT have any exclusions and/or substitutions for any documents pertaining to the RFQ #913

Details: (Please list all exclusions below or attach a separate page(s) as needed)

( 1 3 ) L O N E S T A R C O L L E G E

FELONY CONVICTION / DEBARMENT NOTICE / CLEAN AIR & WATER ACT NOTICE

Texas Education Code Section 44.034, Notification of Criminal History, Subsection (a) states “a person or business entity that enters into a contract with a school district must give advance notice to the district if the person or an LSC or operator of the business entity has been convicted of a felony. The notice must include a general description of the conduct resulting in the conviction of a felony.”

Subsection (b) states “a school district may terminate a contract with a person or business entity if the district determines that the person or business entity failed to give notice as required by Subsection (a) or misrepresented the conduct resulting in the conviction. The district must compensate the person or business entity for services performed before the termination of the contract.” This notice is not required of a publicly-held corporation. (Please CHECK APPROPRIATE BOX below and COMPLETE ALL SIGNATURE BLOCKS.)

Company Name:

Authorized Company Official’s Name (printed):

My firm is a publicly-held corporation, therefore, this reporting requirement is not applicable

My firm is not owned nor operated by anyone who has been convicted of a felony

My firm is owned or operated by the following individual(s) who has/have been convicted of a felony:

Name of Felon(s):

Details of Conviction(s):

Signature of Company Official:

I hereby further certify that my company has not been debarred, suspended or otherwise made ineligible for participation in Federal Assistance programs under Executive Order 12549, “Debarment and Suspension,” as described in the Federal Register and Rules and Regulations.

Signature of Company Official:

I the vendor, am in compliance with all applicable standards, orders or regulations issued pursuant to the Clean Air Act of 1970, as amended (42 U.S.C. 7606), Section 508 of the Clean Water Act, as amended (33 U.S.C.

1368), Executive Order 11738 and Environmental Protection Agency Regulation, 40 CFR Part 31 and as required under OMB Circular A-102. the grantor agency and to the United States Environment Protection Agency Assistant Administrator for the Enforcement.

Signature of Company Official:

Projects Page 11 of 11

(14) QUESTIONNAIRE

(This form must be completed in its entirety and attach to your completed proposal)

Company Name: __________________________________________________________________ Representative’s Name: ____________________________________________________________ Title: ____________________________________________________________________________

FEDERAL PROVISIONS

The following provisions are required and apply when federal funds are expended by Lone Star College for any contract resulting from this procurement process. Please acknowledge that you have read the provisions and will comply accordingly: (See terms and conditions for definition) Yes ____ No ____ Equal Employment Opportunity

Yes ____ No ____ Copeland “Anti-Kickback” Act (18 U.S.C. 874 and 40 U.S.C. 276c)

Yes ____ No ____ Contract Work Hours and Safety Standards act (40 U.S.C. 3701-3708)

Yes ____ No ____ Rights to Inventions Made Under a Contract or Agreement (37 CFR PT 401)

Yes ____ No ____ Davis-Bacon Act as amended (40 U.S.C. 3141-3148)

Yes ____ No ____ Clean Air Act (42 U.S.C. 7401-7671 q.)

Yes ____ No ____ Debarment and Suspension (Executive Orders 12549 and 12689)

Yes ____ No ____ Byrd Anti-Lobbying Amendment (31 U.S.C. 1352)

Yes ____ No ____ Buy American Act (41 U.S.C. 10a-10d)

Initial: ____________________ Date: _______________________

Please acknowledge that you have read the entire proposal to include the terms and conditions and that you have full comprehensive understanding of the requirements in this RFP/RFQ/CSP.

Yes ____ No ____ Initial ______________

END OF FORMS