EXHIBIT_“A”_Proposers_Qualification_Statement.pdf

EXHIBIT “A”

PROPOSER'S QUALIFICATION STATEMENT

The undersigned certifies under oath the truth and correctness of all statements and of all answers to questions made below:

Check One

Submitted By: Corporation Name: Partnership Address: Individual City, State, Zip Other

(describe) Telephone No.

Fax No.

Email

State the true, exact, correct and complete name of the partnership, corporation, trade or other name under which you do business and the address of the place of business.

The full legal name of the Proposer is:

The address of the principal place of business is:

1. If Proposer is a corporation, answer the following:

Date of Incorporation:

State of Incorporation:

President's name:

Vice President's name:

Secretary's name:

Treasurer's name:

Name and address of Resident Agent:

2. If Proposer is an individual or a partnership, answer the following:

Date of organization: ________________ Name, address and ownership percentage units of all partners:

State whether general or limited partnership and confirm it is registered to do business in Florida:

3. If Proposer is other than an individual, corporation or partnership, describe the organization and give the names and addresses of principals:

4. If Proposer is operating under a fictitious name, submit evidence of compliance with the Florida Fictitious Name Statute.

5. How many years has your organization been in business under its present business name?

a) Under what other former names has your organization operated?

6. Indicate registration, license numbers or certificate numbers for the businesses or professions, which are the subject of this RFP. Please attach certificate of competency and state registration.

7. Have you personally reviewed the requirements for the proposed services?

YES NO

8. Do you have a complete set of documents, including drawings and addenda?

YES NO

9. Did you attend the Pre-Proposal Conference if any such conference was held?

10. Have you ever failed to complete any work awarded to you? If so, state when, where and why:

11. State the names, telephone numbers and last known addresses of three (3) owners, individuals or representatives of owners with the most knowledge of services which you have performed and to which you refer (government owners are preferred as references).

Name Address Telephone

12. List the pertinent experience of the key individuals of your organization (continue with an additional sheet, if necessary).

13. State the name and title of the individual who will have responsibility relating to the services:

14. State the name and address of attorney or law firm, if any, for the business of the Proposer:

15. State the names and addresses of all businesses and individuals who own an interest of more than five percent (5%) of the Proposer's business and indicate the percentage owned of each such business:

16. State the names, addresses and the type of business of all firms that are partially or wholly owned by Proposer:

17 State the name of the Surety Company which will be providing the bond, and name and address of agent:

18. Bank References:

Bank Address Telephone

19. Attach a financial statement including Proposer's latest balance sheet and income statement showing the following items:

a) Current Assets (e.g., cash, joint venture accounts, accounts receivable, notes receivable, accrued income, deposits, materials, real estate, stocks and bonds, equipment, furniture and fixtures, inventory and prepaid expenses)

b) Net Fixed Assets

c) Other Assets

d) Current Liabilities (e.g., accounts payable, notes payable, accrued expenses, provision for income taxes, advances, accrued salaries, real estate encumbrances and accrued payroll taxes)

e) Other Liabilities (e.g., capital, capital stock, authorized and outstanding shares par values, earned surplus, and retained earnings).

20. State the name of the firm preparing the financial statement and its date:

21 Is this financial statement for the identical organization named on page one?

22. If not, explain the relationship and financial responsibility of the organization whose financial statement is provided (e.g., parent-subsidiary).

The Proposer acknowledges and understands that the information contained in response to this Qualification Statement shall be relied upon by the City in awarding a contract and such information is warranted by Proposer to be true. The discovery of any omission or misstatement that materially affects the Proposer's qualifications to perform under the contract shall cause the City to reject the proposal, and if after the award, to cancel and terminate the award, contract or both.

Signature

Print Name

Title

Date

STATE OF )

COUNTY OF ________________ )

BEFORE ME, an officer duly authorized by law to administer oaths and take acknowledgments, personally appeared ☐ physical presence or ☐ online notarization, on

_________________ as _________________, of ___________________, an organization authorized to do business in the State of Florida, and acknowledged and executed the foregoing Statement as the proper official of _______________________ for the use and purposes mentioned in it and affixed the official seal of the entity, and that the instrument is the act and deed of that entity. He/she is personally known to me or has produced __________________________ as identification.

IN WITNESS OF THE FOREGOING, I have set my hand and official seal at in the State and

County aforesaid on this _____ day of _________________, 20__.

Notary Seal Signature of Notary Public

Printed Name of Notary Public