PQQ039_Contractor_Responsibility_Q.pdf

Solicitation #HSCG88-16-B-PQQ039

CONTRACTOR’S RESPONSIBILITY QUESTIONAIRE

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 contracting officer in this determination, please complete the following questionnaire. THE

GOVERNMENT WILL TREAT ALL INFORMATION SUBMITTED ON THIS FORM AS

CONFIDENTIAL. THE DATA IS FURTHER DEEMED BY THE OFFEROR TO CONTAIN

TRADE SECRETS AND COMMERCIAL OR FINANCIAL INFORMATION THAT IS

PRIVILEGED AND CONFIDENIAL UNDER 5 U.S.C. 552.

PLEASE PRINT OR TYPE ALL INFORMATION:

FIRM’S NAME:______________________________________________________________

PRIMARY TYPE OF BUSINESS:_______________________________________________

STREET ADDRESS:__________________________________________________________

CITY: _____________________________STATE AND ZIP CODE:____________________

MAILING ADDRESS:_________________________________________________________

CITY: _____________________________STATE AND ZIP CODE:____________________

PHONE NUMBER:__________________________FAX NUMBER:____________________

PRINCIPAL OWNER:_________________________________________________________

PRINCIPAL OWNER’S E-MAIL: _______________________________________________

PARTNERS/CORPORATION MEMBERS:________________________________________

IF A CORPORATION, WHEN WAS IT FORMED:____________________STATE:________

BANK NAME:________________________________________________________________

STREET ADDRESS:__________________________________________________________

CITY: _____________________________STATE AND ZIP CODE:____________________

PHONE AND FAX NUMBER:____________________________________________________

BUSINESS ACCOUNT NUMBER:________________________________________________

WHEN ACCOUNT WAS ESTABLISHED:__________________________________________

CONTACT AT BANK (Name / Phone number / E-mail) : _____________________________

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:

SUPPLIER #1:

CONTACT NAME:_____________________________________________________________

E-MAIL: _____________________________________________________________________

ADDRESS:____________________________________________________________________

CITY: _____________________________STATE AND ZIP CODE:______________________

PHONE NUMBER:__________________________FAX NUMBER:_____________________

ACCOUNT NUMBER:___________________________________________________________

TYPE OF MATERIAL PURCHASED:______________________________________________

SUPPLIER #2:

CONTACT NAME:_____________________________________________________________

E-MAIL: _____________________________________________________________________

ADDRESS:____________________________________________________________________

CITY: _____________________________STATE AND ZIP CODE:______________________

PHONE NUMBER:__________________________FAX NUMBER:_____________________

ACCOUNT NUMBER:___________________________________________________________

TYPE OF MATERIAL PURCHASED:______________________________________________

SUPPLIER #3:

CONTACT NAME:_____________________________________________________________

E-MAIL: _____________________________________________________________________

ADDRESS:____________________________________________________________________

CITY: _____________________________STATE AND ZIP CODE:______________________

PHONE NUMBER:__________________________FAX NUMBER:_____________________

ACCOUNT NUMBER:___________________________________________________________

TYPE OF MATERIAL PURCHASED:______________________________________________

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

PROJECT #1:

PROJECT TITLE:_______________________________________________________________

LOCATION:___________________________________________________________________

TYPE OF PROJECT:____________________________________________________________

DOLLAR VALUE OF PROJECT: $_________________________________________________

AGENCY/OWNER:_____________________________________________________________

POINT OF CONTACT:____________________PHONE/FAX NUMBER:__________________

E-MAIL: _____________________________________________________________________

PROJECT #2:

PROJECT TITLE:_______________________________________________________________

LOCATION:___________________________________________________________________

TYPE OF PROJECT:____________________________________________________________

DOLLAR VALUE OF PROJECT: $_________________________________________________

AGENCY/OWNER:_____________________________________________________________

POINT OF CONTACT:____________________PHONE/FAX NUMBER:__________________

E-MAIL: _____________________________________________________________________

PROJECT #3:

PROJECT TITLE:_______________________________________________________________

LOCATION:___________________________________________________________________

TYPE OF PROJECT:____________________________________________________________

DOLLAR VALUE OF PROJECT: $_________________________________________________

AGENCY/OWNER:_____________________________________________________________

POINT OF CONTACT:____________________PHONE/FAX NUMBER:__________________

E-MAIL: _____________________________________________________________________