Qualifications Questionaire 25- 15864AP-RB.docx

Qualifications Questionnaire Pavement Striping, Project Number: 7093H-RB

Date Submitted: ______________ All questions must be answered completely. If necessary, the bidder may supply any additional information and submit with this statement. This statement must be returned with your proposal.

1. Name of bidder: ___________________________________________________________________

2. Permanent main office address: ______________________________________________________

3. When organized: __________________________________________________________________

4. A. If corporation, State incorporated in: ________________________________________________

B. Date of last filing with Secretary of State: _____________________________________________

5. How many years have you been engaged in pavement striping? ___________________

6. A. Under what firm name(s) and how long under each? __________________________________ _________________________________________________________________________________

B. How long has each company been bonding work? _____________________________________

7. Have you worked for Jefferson County before? ______________ A. If so, what project(s)? (Note: If more than 3 projects, attach a separate sheet.)

1. ___________________________________________________________________________

2. ___________________________________________________________________________

3. ___________________________________________________________________________

8. On a separate sheet of paper, list all projects that your firm has been a general contractor for governmental agencies in the past three years that are like this proposed project. Provide the following for each project:

· Project name and location;

· Contractor contact person and phone number;

· Agency name and address;

· Agency contact person and phone number;

· Contract dollar amounts, original and final with explanation if they different;

· Contract duration, original and final with explanation if they different;

· Liquidated damages or other delay claims, if any;

· Unique project challenges (add photos, if desired).

9. List general type(s) of work performed by you. ___________________________________________

10. Liquidated damages and/or disputes: List all government agency projects in the last three (3) years where liquidated damages were or may be assessed; current or previous substantial disputes or protests. Attach explanation in detail. ____________________________________________________________________________________________________________________________________________________________________

11. A. Have you ever failed to complete any work satisfactorily that was awarded to you by a government agency? __________________________________

B. If yes, where and why? ___________________________________________________________ C. Was that work completed within the original duration? _________________________________

D. Was the contract bonded? _______________________________________________________

E. Was there a claim made and settled against the bond? _________________________________

12. A. Do you anticipate subcontracting work under this contract? _____________________________

B. If yes, what percent to total contract? ___________________%

C. List subcontractors: ______________________________________________________________

13. List the background and experience of the principal members of your organization who will be involved with this project.

Name Title Experience Years at Firm

15. A. Have any charges been filed against you, your firm, or the bidding entity, with the Office of Contract Compliance, the Equal Opportunity Commission, a state government civil rights commission, or any similarly constituted entity of anti-discrimination legislation or regulations? __________________ B. If yes, give details:

C. Will you, upon request, fill out a detailed financial statement and furnish any other information that may be required by the County? ________________________________________________ THE UNDERSIGNED HEREBY AUTHORIZES AND REQUESTS ANY PERSON, FIRM, OR CORPORATION TO FURNISH ANY INFORMATION REQUESTED BY THE COUNTY IN VERIFICATION OF THE RECITALS COMPRISING THIS QUALIFICATIONS QUESTIONNAIRE AND THAT THE ANSWERS TO THE FOREGOING QUESTIONS AND ALL STATEMENTS THEREIN CONTAINED ARE TRUE AND CORRECT.

NAME OF COMPANY

AUTHORIZED SIGNATURE

PRINTED NAME

TITLE

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