Prequalification_Questionnaire for Public Works~5.pdf

BID NUMBER CONTRACTOR LICENSE

NUMBER

(PLEASE CIRCLE) INDIVIDUAL CORPORATION

MBE o WBE o DSBE o

STATE CAPITALIZATION

NAME

ADDRESS

NAME

ADDRESS

NAME

ADDRESS

NAME

ADDRESS

NAME

ADDRESS

YEARS

YEARS

of submission of this questionnaire must be forwarded to the Procurement Commissioner immediately. Failure to do so, without limiting other remedies available to the City, may result in the disqualification of the seller from award(s) under this Program.

*No bid will be accepted unless this questionnaire with all questions fully answered, is filed with the Department having jurisdiction over the work proposed, on or before the date specified by the Procurement Department.

*All information provided by a Seller in this questionnaire shall be used by the City in determining and assessing a Seller's qualifications and responsibility in accordance with Chapter 17-100 of The Philadelphia Code.

*The City reserves the right to investigate any statement made herein, by means of information included in but not limited to that contained in this questionnaire. Any misrepresentation of fact, as determined by the City, may result in the disqualification of a seller.

*Any material change in the financial, corporate, or business status of a qualifying seller that occurs subsequent to the time

*All information on this questionnaire will be held strictly confidential, to the extent permitted by law.

City of Philadelphia

QUESTIONNAIRE AND FINANCIAL STATEMENT

SUBMITTED BY PARTNERSHIP

PRINCIPAL OFFICE ADDRESS

FOR QUALIFYING SELLERS

VICE PRESIDENT

SECRETARY

TREASURER

GENERAL LIMITED

PRESIDENT

PRINCIPAL OFFICE TELEPHONE NUMBER E-MAIL ADDRESSPRINCIPAL OFFICE FAX NUMBER

DATE SUBMITTED FEDERAL EIN NUMBER CITY BUSINESS TAX IDENTIFICATION #

CORPORATION

OEO REGISTRATION

2. How many years experience has your organization had as a prime contractor in the type of construction work for

3. How many years experience has your organization had as a subcontractor in the type of construction work for

EXPERIENCE AND EQUIPMENT

which you seek qualification?

1. How many years has your organization been in business as a contractor under its present business name?

On a separate sheet of paper, list all other business names under which your organization has been in business as a construction contractor?

PARTNERSHIP

DATE OF INCORPORATION DATE OF ORGANIZATION TYPE

OFFICER PARTNERS

YEARS

as (1) a general contractor $ (2) a subcontractor $

1.

2.

5. On a separate sheet of paper, describe the construction experience of the principal officers and managers (including superintendents) of your organization. Include: name of the individual and postion/office, years of construction experience, type of work in which the individual has experience (including size of project worked on), names of organizations worked for and positions/ responsibilities held, union affiliations.

4. State the largest dollar amount of work your organization has done in any single year during the last five years

If "YES", state the City contract number and project name and attach an explanation of the circumstances surrounding the declaration of default or termination.

Has a commercial surety for your organization, within the last five years, been called upon to complete any work on a contract with the City?

Please circle YES NO

If "YES", state the name of the individual, the name and address of the organization, the City contract number and project name for the contract under which work was not finally accepted, and attach a detailed explanation of the circumstances surrounding the non-acceptance.

7. Has the City, within the last five years, declared your organization in default of a City contract or otherwise terminated the contract?

Please circle YES NO

If "YES", state the City contract number and project name and attach an explanation of the circumstances surrounding the non-acceptance.

Has any officer, partner, or other person active in the management of your organization, within the last five years, been an officer, partner, manager, or sole proprietor of another organization which performed work for the City that was not finally accepted by the City?

Please circle YES NO which you seek qualification?

6. Has your organization within the last five years performed work for the City of Philadelphia that was not finally accepted by the City? Please circle YES NO complete a City Contract? Please circle YES NO

If "YES", state the City contract number and project name and a detailed explanation of the circumstances.

Has any officer, partner, or other person active in the management of your organization, within the last five years, been an officer, partner manager, or sole proprietor of another organization whose commercial surety was called upon to complete any work on a contract with the

City? Please circle YES NO

If "YES", attach a detailed explanation identifying the owner and bid/contract numbers (if applicable) for the project, stating whether the owner declared your organization in default of its contract, and describing the project, the type of work, the dates the work was started and

If "YES", state the name of the individual, the name and address of the organization, the City contract number and project name for the contract the surety was called upon to complete, and attach an explanation of the circumstances.

8. Has any officer, partner, or other person active in the management of your organization, within the last five years, been an officer, partner, manager, or sole proprietor of another organization that was declared in default of a City contract or otherwise terminated, or that failed to stopped and the reasons the work was not completed.

10. Has any officer, partner, or other person active in the management of your organization ever been an officer, partner, manager, or sole proprietor of another organization that failed to complete or was declared in default of a contract for a public or private owner

If "YES", state the name of the individual, the name and address of the organization, the City contract number and project name for the contract defaulted or terminated and attach an explanation of the circumstances surrounding the declaration of default or termination.

9. Has your organization ever failed to complete any work under, or been declared in default of, a contract awarded to it by a public or private owner other than the City of Philadelphia? Please circle YES NO

11. Has any officer, partner, or other person active in the management of your organization within the last five years been disqualified, suspended, or debarred (under its present name or any other name) from bidding on public contracts, or removed from a bidders' list, by any state or federal agency, or by the City of Philadelphia? Please circle YES NO

If "YES", state the agency that took such action, the date(s) of the action, the type of work to which the contract(s) applied, and the reasons other than the City of Philadelphia? Please circle YES NO

If "YES", state the name of the individual and attach a detailed explanation identifying the owner and bid/contract number (if applicable) stating whether the owner declared the organization in default of its contract, and describing the project, the type of work, the date the and stopped, the individual's role in the project, and the reasons the work was not completed.

13. Has your organization or any officer, partner, or other person active in the management of your organization, or any shareholder holding an equity interest of more than five percent, ever been convicted of or pleaded guilty or nolo contendre to federal or state misdemeanor or felony charges (including but not limited to, charges related to public bidding law or the making of false statements)? Please circle YES NO stated by the agency for the action.

12. Has any commercial surety ever refused to furnish a performance or payment bond for your organization? Please circle YES NO

If "YES", state the name and address of the surety, describe the contract for which the bond was refused (including the owner, date of contract, and type of work), and state the reasons for the refusal. Attach a letter from your surety company indicating your total bonding limit and current aggregate risk.

ever been refused coverage under any fidelity bond? Please circle YES NO

Is your organization or any officer, partner, or other person active in the management of your organization, or any shareholder holding an

1.

2.

or more.

BID NUMBER

CONTRACT NO. % COMPLETE

If you answered YES to either of the above questions, please attach an explanation of details identifying the claimant and stating the grounds asserted by the claimant and stating the disposition.

20. Do you have any pending, contemplated or ongoing administrative or judicial proceedings material to your organization's business or finances including, but not limited to, any litigation, consent orders or agreements with any state or federal regulatory agency issued to your organization?

If you answered YES, please attach an explanation.

currently under indictment on federal or state misdemeanor or felony charges? Please circle YES NO currently the subject of a state or federal grand jury investigation or under notification by local, state or federal law enforcement authorities that they are the subject of any criminal investigation? Please circle YES NO equity interest of more than five percent,

14. Has any officer, partner, director, shareholder, or other person active in the management of your organization been employed by the City of Philadelphia, or been appointed to a political or other office of the City? Please circle YES NO

If "YES" attach the following information: the name of the individual; position held with the City; the dates the employment or appointment began and terminated.

If your answer to any of the foregoing questions is YES, attach a detailed description that includes the following:

* the nature of the conviction, plea, indictment, bond refusal, and/or grand jury or criminal investigation;

* the name of each individual who was the subject of such action;

* their position in your organization;

* the jurisdiction or entity taking the action; the date(s) the action was taken; the nature of the charges that were the subject of the action; and all other circumstances relevant to the action.

18. Is your organization or any of its parent or subsidiary organizations currently indebted to the City of Philadelphia for any delinquent

City taxes, taxes collected by the City on behalf of the School District of Philadelphia, liens, judgments, fees or other debts? Please circle YES NO

If YES, attach an explanation describing the nature and amount of the debt, lien, judgment, or fee; the dates of any notices from the City;

and any written agreement or payment plan with the City for its disposition.

15. Identify, by name and business address, all organizations that are affiliates or subsidiaries of your organization, and state their relationship to your organization. Attach separate sheet of paper as needed.

16. Identify, by name and business address, any other organization and any individual (other than officers, partners, and managers of your

17. Identify all individuals and organizations, by name and business address, that hold a financial interest in your organization of ten percent organization) that control or influence bidding by your organization.

Please circle YES NO

If your organization has had construction contracts with the City of Philadelphia, provide the following information:

List all COMPLETED City of Philadelphia contracts within the last five years (attach additional paper as needed):

CONTRACT NUMBER PROJECT DESCRIPTION AMOUNT OF CONTRACT

19. Have any liquidated damages or other penalties been imposed by the City on your organization? Please circle YES NO

Have any liens, claims or stop notices been filed against your organization? Please circle YES NO

List all INCOMPLETE contracts (City or otherwise) held by your organization at present. (Please attach additional sheets as needed.)

CONTRACTING ENTITY LOCATION AMOUNT OF CONTRACT

DATE

Name Phone Number

Name

Phone Number

Name

Phone Number

Name

Phone Number

DATE

Name

Phone Number

Name

Phone Number

Name

Phone Number

Name

Phone Number

Name

Phone Number

Name

Phone Number

List the largest projects that your organization has completed.

DOLLAR AMOUNT CONTRACTING ENTITY REFERENCES

List any projects that your organization has completed that are similar in nature to the project for which you are qualifying.

DOLLAR AMOUNT CONTRACTING ENTITY REFERENCES

List any equipment that is owned by your organization that is available for the proposed work. (Please attach additional sheets as needed.)

Accounts payable

FINANCIAL POSITION AS OF: (Not over 6 months old)

LIABILITIES & EQUITYASSETS

Total Current Assets

Land

Buildings

Machinery and equipment

Accrued and withheld payroll taxes

Accrued expenses

Allowance for doubtful accounts

Notes receivable

Inventories

Prepaid expenses

PROPERTY AND EQUIPMENT

Notes payable

Total Current Liabilities

LONG-TERM LIABILITIES

CURRENT ASSETS CURRENT LIABILITIES

Cash and cash equivalents

Short-term investments

Accounts receivable

Lines of credit

Notes payable - current portion

The City reserves the right to request any additional or clarifying information from Contractor at any time and Contractor is hereby notified that the City may contact any reference, financial institution or other agency identified by Contractor herein for further information. By submission of this pre-qualification statement, Contractor hereby acknowledges the City's right to revoke the qualification of Contractor at any time for reasons including, but not limited to, Contractor exceeding its capacity to perform work. Contractor hereby verifies that all information and documentation submitted herein is true and correct and Contractor acknowledges that the submission of false information by it is subject to the penalties of 18 Pa.C.S. Section 4904 relating to unsworn falsification to authorities.

Total Property and Equipment

Less accumulated depreciation and amortization

Net Property and Equipment

OTHER ASSETS

Trucks and automobiles

Office furniture and equipment

Assets under capital lease

Total Equity

TOTAL LIABILITIES & EQUITY

Please provide the total dollar amount of all available lines of credit at your organization's disposal.

Owner's equity

Total Other Assets

TOTAL ASSETS

Cash surrender value of officer's life insurance

Loans against policies

Notes receivable

Organization costs (net)

FIRM OR CORPORATE NAME

Please provide the total dollar amount of the balance of all available lines of credit at your organization's disposal.

Common stock

Additional paid-in capital

Less treasury stock

Retained earnings

Partner's capital

EQUITY

Total Long-Term Liabilities

Total Liabilities