REQUALIFICATION
Gentlemen:
We are in the process of updating our records for a portion of our bidders list. Please return this completed
form at your earliest opportunity to ensure you remain on the list.
Thank you.
Circle the correct response:
1.
Whom at your organization should we contact (Please include a business card)
Name: _______________________________
Phone No. ____________________________
Cell Phone: ___________________________
Pager: _______________________________
E-mail: ______________________________
2.
Indicate if you are certified DBE MBE WBE
3.
Are you affiliated with AFL/CIO or other union representation YES NO
4.
Bonding Company/Limit:
Name and address of bonding company
_____________________________________________
_____________________________________________
_____________________________________________
Limit:
Have not established bonding capability
$100,000
$500,000
Over $1,000,000 (indicate limit) ______________________________
5.
Experience
5.1
Claims and Suits. (If the answer to any of the questions below is yes, please attach
details.)
5.1.1
Has your organization ever failed to complete any work awarded to it? YES NO
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5.1.2
Are there any judgments, claims, arbitration proceedings or suits pending or
outstanding against your organization or its officers? YES NO
5.1.3
Has your organization filed any law suits or requested arbitration with regard to
construction contracts within the last five years? YES NO
5.1.4
How many mechanics liens has your organization filed in the last five years?
YES NO
5.2
Within the last five years, has any officer or principal of your organization ever been an
officer or principal of another organization when it failed to complete a construction
contract? (If the answer is yes, please attach details.) YES NO
5.3
On a separate sheet, list the major projects your organization has completed in the past
five years, giving the name of project, owner, architect, contract amount, date of
completion and percentage of the cost of the work performed with your own forces.
3.6.1
6.
State average annual amount of construction work performed during the past
five years:
5.4
Has the firm, or any firm listed in response to questions 1.7 and 1.11 above, defaulted or
been terminated on, or had its surety called upon to complete, any contract awarded
within the past five years? If so, give date(s), agency(ies)/owner(s), project(s), contract
number(s), and describe, including the result: YES NO
5.6
For all contracts within the past five years: (a) list and describe any liens or claims filed
against the firm and remaining undischarged or unsatisfied for more than 90 days, and (b)
list and describe all liquidated damages assessed:
Financing
6.1
Financial Statement.
6.1.1
Attach financial statements for the past two years, preferably audited, including
your organization's latest balance sheet and income statement showing
the following items:
Current Assets (e.g., cash, joint venture accounts, accounts receivable,
notes receivable, accrued income, deposits, materials inventory and
prepaid expenses):
Net Fixed Assets:
Other Assets:
Current Liabilities (e.g., accounts payable, notes payable,
accrued expenses, provision for income taxes, advances,
accrued salaries and accrued payroll taxes):
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Other Liabilities (e.g., capital, capital stock, authorized and
outstanding shares par values, earned surplus and retained
earnings).
6.2
7.
6.1.2
Name and address of firm preparing attached financial statement, and date
thereof:
6.1.3
Is the attached financial statement for the identical organization named on page
one? YES NO
6.1.4
If not, explain the relationship and financial responsibility of the organization
whose financial statement is provided (e.g., parent-subsidiary).
Will the organization whose financial statement is attached act as guarantor of the
contract for construction? YES NO
Other Information
Within the past five years, has the firm, any affiliate, any predecessor company or entity, or any person
identified in question number 1 above been the subject of any of the following: (respond to each question
and describe in detail the circumstances of each affirmative answer: attach additional pages if necessary)
a.
a judgment or conviction for any business-related conduct constituting a crime under state or
federal law?
no yes
b.
a criminal investigation or indictment for any business-related conduct constituting a crime under
state or federal law?
no yes
c.
a grant of immunity for any business-related conduct constituting a crime under state or federal
law?
no yes
d.
a federal or state suspension or debarment?
e.
a rejection of any bid for lack of qualifications, responsibility or because of the submission of an
informal, non-responsive or incomplete bid? no yes
f.
a rejection of any proposed subcontract for lack of qualifications, responsibility or because of the
submission of an informal, non-responsive or incomplete bid? no yes
g.
a denial or revocation of pre-qualification?
h.
a voluntary exclusion from bidding/contracting agreement?
i.
any administrative proceeding or civil action seeking specific performance or restitution in
connection with any public works contract except any disputed work proceeding?
no yes
j.
an OSHA Citation and Notification of Penalty containing a violation classified as serious?
no yes
k.
an OSHA Citation and Notification of Penalty containing a violation classified as willful?
no yes
no yes
no yes
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no yes
l.
a prevailing wage or supplement payment violation?
no yes
m.
a State Labor Law violation deemed willful? no yes
n.
any other federal or state citations, Notices, violation orders, pending administrative hearings or
proceedings, or determinations of a violation of any labor law or regulation?
no yes
o.
any criminal investigation, felony indictment or conviction concerning formation of, or any
business association with, an allegedly false or fraudulent women's, minority or disadvantaged
business enterprise?
no yes
p.
any denial, decertification, revocation or forfeiture of Women's Business Enterprise, Minority
Business Enterprise or Disadvantaged Business Enterprise status?
no yes
q.
rejection of a low bid on a State contract for failure to meet statutory affirmative action or M/WBE
requirements? no yes
r.
a consent order with the NYS Department of Environmental Conservation, or a federal, state or
local government enforcement determination involving a violation of federal or state
environmental laws?
no yes
s.
any bankruptcy proceedings?
t.
any suspension or revocation of any business or professional license?
u.
any citation, Notices, violation orders, pending administrative hearings or proceedings or
determination for violations of:
no yes
no yes
-
federal, state or local health laws, rules or regulations
-
unemployment insurance or workers compensation coverage or claim requirements
no yes
-
ERISA (Employee Retirement Income Security Act) no yes
-
federal, state or local human rights laws
-
federal or state security laws
no yes
no yes
None of the above
06/28/16
no yes