RFP_Public_Testing_18347_Exhibit_C.docx

Exhibit C - Qualifications Proposal State of Minnesota Real Estate and Construction Services (State) Qualifications and General Requirements Information Do not use forms other than those provided herein. The forms provided indicate what information is desired and the format in which it is to be presented. When filling out this form, refer back to the specific items asked under the Scoring Criteria section of the RFP.

Project Information Provide State’s project number, project name, and location of the project for which this form is being submitted.

0. Project Number (from RFP): 55AK0054

0. Project Name (from RFP): Special Inspections/Construction Material Testing AMRTC Bed Expansion (Miller Bldg.) at Anoka Metro Regional Treatment Center, Anoka, MN

0. Project Location (from RFP): Anoka, MN Responding Firms Information Provide legal name and address and contact person information on the prime firm that is responding to the RFP. If the firm is forming a joint venture or an association with other firm(s) for this project, insert: “in association with” or “in joint venture with” and name the firm(s). Provide addresses of joint venture or associate firm in the section number 4.0 below.

List the name, title, and telephone number of the principal who will serve as the point of contact. Such an individual must be empowered to speak for the responding firm on policy and contractual matters and should be familiar with the programs and procedures of responding firm.

d. Responder’s Name & Address (include 9 digit zip code):

e. County of responder’s location:

f. Responder’s State Vendor Number:

g. Date firm was established:

h. Name, title & telephone number person signing proposal (see section 10.0):

i. Responder’s (contact) telephone number:

j. Responder’s Fax Number:

k. Responder’s Email Address:

Responding Firms Interest and Availability Responder’s should provide statements on the Responder and design team’s interest and availability to promptly perform the services called for in the RFP.

l. Responder’s statement of interest to perform the services as indicated in the RFP:

m. Responder’s statement on availability to start work promptly upon execution of contract and to promptly deliver services:

Subconsultants Proposed for this Project If Responder intends to use outside (as opposed to in-house) consultants, provide name(s) and address(es) of all such firm(s) and name of principal person(s), as well as the particular areas of technical/professional expertise, as it relates to this project. Previous working relationships should be noted. Fill out below for each subconsultant proposed for this project. Add additional pages if necessary.

(yes or no)

Resumes of Key Personnel Provide brief resumes of key personnel expected to participate on this project. Limit resumes to only those personnel and specialists who will have major project responsibilities. Work completed while employed with other firm(s) may be included as long as firm name and location is identified. Add additional pages if necessary.

Qualifications Work by responder and its consultants which best illustrates current qualifications relevant to this project. List projects completed by the firm submitting this application. Work performed by other segments of the firm not located within the confines of the office submitting this application, or work completed by individuals while employed with other firms, should not be listed.

Projects listed must have been no more than 10-years from date of request for proposal. Prime consideration will be given to projects that illustrate responder’s capability for performing work similar to that described in this RFP. Add additional pages if more space is needed.

Client name, location, project title, client contact person, title, phone number, email address (completed by A/E of record)

Approach, Methodology and Work Plan Describe your understanding of the Project. Responder should include their approach, methodology, work plan including schedule with milestone dates. Discuss the significant issue(s) to be addressed and your specific approach to the planning, design and construction process:

Unique Qualifications Summarize your team’s unique qualifications for this Project and include any specialized or technical certifications that your firm or members of your firm may have:

Eligibility Requirements Respond to each statement below and attach completed documents as required to confirm specific eligibility requirements.

n. I have read and agree to the State/Professional and Technical Services Contract: Yes |_| No |_|

o. A Certificate of insurance will be provided in accordance with State/ Professional and Technical Services Contract, if awarded project Yes |_| No |_|

p. A signed Affidavit of Non-collusion is attached. Yes |_| No |_|

q. A completed and signed Workforce Certificate is included with this proposal, if applicable: Yes |_| No |_| N/A |_|

r. Foreign outsourcing will |_| will not |_| be involved in the delivery of contract services.

Authorized Signature The proposal must be signed in ink by an authorized member/officer of the Responder. If a corporation person must be authorized in a corporate resolution or partnership document; if a sole proprietor, owner must sign. All information contained in this form must be current.

s. Typed name of authorized signor:

t. Typed title of authorized signor:

u. Authorized signature(signature of person identified in Section 2):

v. Date Signed:

w. Registration Number*:

*State registration/license number for the practices of professional engineering, architecture, land surveying, landscape architecture, geoscience, or use of title for certified interior design assigned by the State Registration Board (http://mn.gov/aelslag/roster.html).

x. Person signing is (select from dropdown):

**provide copy of corporate resolution or by-laws

y. Firm is registered in Minnesota as a (selection from dropdown list):, if other, explain

z. MN Tax ID Number:

aa. FED Tax ID Number:

ab. MN Vendor Number (required for contract):

END OF EXHIBIT C

05/18/2016 – Exhibit C-Qualifications Proposal Page 3 of 5