Responsible_Contractor_Questionnaire_Form_A.pdf

Responsible Contractor Questionnaire Form A

Please complete the following information related to the company making the bid. This form is intended to give information related to the company.

Contract Number:

Are you completing this form as a: Contractor Subcontractor

Company Name:

Point of Contact

Name:

Phone:

Email:

Company Owner(s):

Principle Staff Names:

Please provide a list of any names this company has done business as before and explain any changes to the name.

Is your company controlled now or has been in the past five years by another company or business entity? No Yes

If yes, please attach a statement detailing the nature of the relationship and if the relationship could impact the contract performance.

Have you ever been disbarred, found non-responsible, non-compliant by a federal, state or local government before? No Yes

If yes, please attach a statement detailing the situation.

Submit the following additional information or a statement that it does not exist/apply for your company:

Please attach a copy of a balance sheet, statement of operations, bonding capacity or other audited financial information that is current within the past 12 months that can demonstrate your financial capacity to start and follow through with the project.

List of relevant state and local licenses including license numbers.

List of litigation and arbitration current pending or occurred within the past five years. Include an explanation of legal claims, parties, court/forum, damages and the resolution.

Proof of insurance including amount of coverage for liability, property damage, workers compensation, and any other insurance required by contract documents.

A statement affirming that craft employees are paid current wage rates, and benefits as required under federal and state law.

A statement acknowledging their obligation to comply with this ordinance in each contract and subcontract.