RFQQ 25-05 – Ex A-2 Contractor's Profile&Refs.pdf

EXHIBIT A-2 – CONTRACTOR’S PROFILE & REFERENCES: RF___ No. ___-___

EXHIBIT A-2 – CONTRACTOR’S PROFILE & REFERENCES

Competitive Solicitation: RF___ No. ___-___ issued ________________________, _____

CONTRACTOR’S INFORMATION PROFILE

Contractor: ___________________________ Type/print full legal name of Contractor

Contractor’s Address:

Business Name

Address

City, State, Zip Code

Contractor’s Unified Business

Identifier Number (UBI):

Note: A nine digit UBI number is assigned to each registered business in Washington.

UBI No. ___ ___ ___

Contractor’s Taxpayer Identification Number (TIN):

Note: Your TIN will be either a number issued by the IRS (e.g., Employer

Identification Number, Federal Tax Identification Number) or a number issued by the Social Security Administration (i.e., your Social Security Number). Do Not provide a Social Security Number.

Is your firm certified as a minority- or woman-owned business with the Washington State Office of Minority and Women’s Business Enterprises (OMWBE)?

Yes No

If yes, provide Contractor’s MWBE certification no.:

Is your firm a self-certified Washington

State Small Business?

Note: See Exhibit A-1 – Contractor’s Certification for criteria to qualify as a

Washington State Small Business.

Note: Regardless of size, a qualifying business must be owned and operated independently from all other businesses. In regard to size, the gross revenue thresholds, as reported on Contractor’s tax returns, are as follows:

Microbusiness: Annual gross revenue of less than $1,000,000

Minibusiness: Annual gross revenue of more than $1,000,000, but less than $3,000,000 Small Business: Annual gross revenue of less than $7,000,000 over each of the three prior consecutive years.

If yes, provide the location for Contractor’s principal place of business:

Street Address

City, State, Zip Code

If yes, what is your business size (based on annual gross revenue)?

Microbusiness

Minibusiness

Small Business

Is your firm certified as a Veteran-Owned Business with the Washington State Department of Veteran Affairs?

Note: See Exhibit A-1 – Contractor’s Certification for criteria to qualify as a

Certified Veteran-Owned Business.

If yes, provide Contractor’s WDVA certification no.:

CONTRACTOR’S PRIMARY POINTS OF

CONTACT:

Authorized Representative:

Name:

Email:

Phone:

Contract Administrator:

Name:

Phone:

REFERENCES

Provide at least three (3) references for Contractor including company name, contact name, title, phone number, email address, and a description of the work engagement upon which the reference is based.

CONTRACTOR REFERENCES

Company Name:

Contact Name:

Title:

Phone:

Description of Work Engagement:

Company Name:

Contact Name:

Title:

Phone:

Title:

Phone:

Title:

Phone:

Email:

Description of Work Engagement:

Company Name:

Contact Name:

Title:

Phone:

SUBCONTRACTORS

Identify authorized subcontractors who will provide service on a contract resulting from this solicitation.

LEGAL NAME SMALL, WOMEN

OWNED, VETERAN OR

OTHER

DISADVANTAGED

STATUS

POINT OF CONTACT

NAME

PHONE NUMBER EMAIL ADDRESS

Return this Contractor’s Profile & References to the RF___ Coordinator at: