IDNR Statement of Interest_5.pdf

IL 532 3046

ADM 236 Rev.12/2022 Statement of Interest (SOI) Form Page 1 of 8

Professional Services Qualifications - Statement of Interest (SOI) Form

1. Please Attach Prequalification Letter to SOI Form

2. Firm Name, address, phone & fax numbers

For Joint Venture (JV), include information for all members, design discipline of each member, and percentage (of total design team) of services of each member.

Firm Name:

Address:

Phone:

Fax:

3. Contact Person: Email:

4. BidBuy Number:

Project Number: Description:

5. Approximate distance to project location:

6. Percentage of work to be completed by Prime / JV:

Miles (Enter n/ a if location has not been determined.)

Certified by CMS?: MBE WBE VOSB SDVOSB NA

7. Percentage of work to be performed by Subcontractors that are CMS Certified MBE / WBE firms:

Percentage of work to be performed by Subcontractors that are CMS Certified VOSB / SDVOSB (VBE) firms:

*Percentages shall reflect the total of all Subcontractors that are MBE / WBE and VOSB / SDVOSB (VBE) in item 11.

8. Certifications & Disclosures. Submit Forms A or B.

Form A Form B (only if vendor is registered in the Illinois Procurement Gateway (IPG)) Approved IPG Registration Number:

9. IDNR Standard Business Terms and Conditions Enclosed:

ADM 236 Rev.12/2022 Statement of Interest (SOI) Form Page 2 of 8

10. Team personnel, by discipline, to be designated for this project including all Subcontractors.

Indicate personnel licensed in Illinois. Submit a résumé for each individual listed below in Item 14. Do not include clerical and support staff.

Personal by Discipline

# Assigned to this project

# Licensed in Illinois

Personnel by Discipline to this project

# Licensed in Illinois

Personnel by Discipline to this project

# Licensed in Illinois

Architects Env. Scientist/Technician Surveyors

Asbestos Project Designers Geologists Other:

Civil Engineers Mechanical Engineers Other:

Construction Observers Risk Assessors Other:

Electrical Engineers Structural Engineers Totals

ADM 236 Rev.12/2022 Statement of Interest (SOI) Form Page 3 of 8

11. Subcontractors Please list the Subcontractors that will be performing any portion of basic design services for this project. Any firm providing architectural, engineering, or land surveying must be prequalified with CDB or IDOT. The firms listed below are considered first tier Subcontractors and shall hold a contract directly with the firm submitting this SOI Form. Failure of the Subcontractors providing regulated design services to be prequalified will result in rejection of the Prime A/E’s submittal(s).

Add additional pages if needed.

Firm Name & Address Detailed Scope of Services

Percentage*: Worked with Prime? Prequalification or Registration Number: Certified by CMS?

ADM 236 Rev.12/2022 Statement of Interest (SOI) Form Page 4 of 8

12. Relevant Project Experience On completed projects within the past 10 years, limit to 8 projects for the submitting firm and 4 for each subcontractor.

For prime vendors, only 4 projects can be government and 4 can be from private entities. Of the 4 government projects, only 1 can be for IDNR.

For subcontractors, only 2 projects can be government and 2 can be private entities. Of the 2 government projects, only 1 can be for IDNR. One project per page, add additional pages as needed.

Firm Name:

Project Description & Location

Level of Responsibility & Detailed Description of Services

Project Contact Prime Contact Phone and Fax Number (Subcontractors, identify the Prime A / E.)

Project Start Date:

Project End Date:

Total Project Cost:

Project came in as budgeted?

ADM 236 Rev.12/2022 Statement of Interest (SOI) Form Page 5 of 8

13. Team Personnel Any contract awarded in response to this submittal is conditioned on the qualifications of the firm and the project team individuals as stated below. Therefore, the team listed below shall be assigned to this project if a contract is awarded to the submitting firm. Add additional rows as needed.

Name Project Assignment Associated Firm Individual Professional License(s) or Certification(s)

Licensed or Certified in Illinois?

Yes or No

ADM 236 Rev.12/2022 Statement of Interest (SOI) Form Page 6 of 8

14. Team Personnel Résumés (Add copies of this page as needed for each team member)

(a) Name and Title (b) Project Assignment

(c) Complete Office Address for this Individual (d) Years of Experience with this Firm (with other firms)

(e) Education: Institution / Field of Study / Degree / Year Obtained (f) Active Licenses / Certifications / Type / Year

(g) Specific Relevant Project Experience Including Individual's Level of Responsibility

ADM 236 Rev.12/2022 Statement of Interest (SOI) Form Page 7 of 8

15. Proposed Method of Accomplishing the Project's Objectives

ADM 236 Rev.12/2022 Statement of Interest (SOI) Form Page 8 of 8

16. Commitment to Completing the Work Please list and provide an explanation of all existing projects. Explain the commitment and availability of key personnel and your ability to complete the work in the time required.

17. Form must be signed by the Firm’s President, Vice President, Partner or Sole Owner, Joint Venture Designee or any other person authorized to execute business for the firm/JV.

Printed Name:

Signature: Date: