Contractor Responsibility Questionnaire.doc

CONTRACTOR’S RESPONSIBILITY QUESTIONNAIRE

Following bid opening and prior to award, the Contracting Officer must determine if the Contractor selected for the proposed award is responsible within the meaning of Federal Acquisition Regulations Section 9.103. The primary factors that influence this determination are, the Firm’s ability to perform the required work, and the Firm’s financial capability. To assist the contracting officer in this determination, please complete the following questionnaire. THE GOVERNMENT WILL TREAT ALL INFORMATION SUBMITTED ON THIS FORM AS CONFIDENTIAL. THIS DATA IS FURTHER DEEMED BY THE OFFEROR TO CONTAIN TRADE SECRETS AND COMMERCIAL OR FINANCIAL INFORMATION THAT IS PR9VILEGED AND CONFIDENTIAL UNDER 5 U.S.C.552.

PLEASE PRINT OR TYPE ALL INFORMATION

FIRM’S NAME:_______________________________________________________________________

PRIMARY TYPE OF BUSINESS:________________________________________________________

STREET ADDRESS:___________________________________________________________________

CITY:_____________________________________________STATE:___________________________

MAILING ADDRESS:___________________________________CITY:_______________________STATE:_____

PHONE: ___________________________________FAX:_____________________________________

PRINCIPAL OWNER:__________________________________________________________________

PARTNERS/CORPORATION MEMBERS:_________________________________________________

IF A CORPORATION WHEN WAS IT FORMED:______________________________STATE:______

CONTRACTOR ESTABLISHMENT CODE DUN #__________________________________________

BANK NAME:________________________________________________________________________

ADDRESS:__________________________________________CITY:_______________STATE:______

TELEPHONE NO:_____________________________________________________________________

BUSINESS ACCOUNT NO:_____________________________________________________________

WHEN WAS ACCT. ESTABLISHED:_____________________________________________________

CONTACT AT BANK:_________________________________________________________________

PLEASE PRINT OR TYPE ANSWERS

Please list three projects your firm has completed in the past two years, and provide a contact name and phone number:

1. PROJECT TITLE:__________________________________________________________

LOCATION:___________________________________________________________________

TYPE OF PROJECT:____________________________________________________________

DOLLAR VALUE OF PROJECT:__________________________________________________

AGENCY/OWNER:_____________________________________________________________

POINT OF CONTACT:______________________PHONE/FAX NOS:____________________

2. PROJECT TILE:___________________________________________________________

LOCATION:___________________________________________________________________

TYPE OF PROJECT:____________________________________________________________

DOLLAR VALUE OF PROJECT:__________________________________________________

AGENCY/OWNER:_____________________________________________________________

POINT OF CONTACT:____________________PHONE/FAX NOS:______________________

3. PROJECT TITLE:____________________________________________________________

LOCATION:___________________________________________________________________

TYPE OF PROJECT:____________________________________________________________

DOLLAR VALUE OF PROJECT:__________________________________________________

AGENCY/OWNER:_____________________________________________________________

POINT OF CONTACT:____________________PHONE/FAX NOS:______________________

List three material suppliers whom you have an open account with, and have done business with for at least three years. Provide contact names and phone numbers:

CONTACT NAME:_________________________PHONE/FAX NOS:____________________

FIRM NAME:__________________________________________________________________

ADDRESS:____________________________________________________________________

CITY:________________________________STATE:__________________________________

ACCOUNT NUMBER:__________________________________________________________

TYPE OF MATERIAL PURCHASED:______________________________________________

CONTACT NAME:____________________________PHONE /FAX NOS:________________

FIRM NAME:__________________________________________________________________

ADDRESS:____________________________________________________________________

CITY:_________________________________________STATE:_________________________

ACCOUNT NUMBER:__________________________________________________________

TYPE OF MATERIAL PURCHASED:______________________________________________

CONTACT NAME:_________________________PHONE /FAX NOS:___________________

FIRM NAME:__________________________________________________________________

ADDRESS:____________________________________________________________________

CITY:______________________________________________STATE:____________________

ACCOUNT NUMBER:__________________________________________________________

TYPE OF MATERIAL PURCHASED:______________________________________________

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