APPENDIX A – REV. 1
QUALIFICATION RESPONSE FORM
Surrey Reference No.: 1220-050-2013-003
Name of Respondent Company:__________________________________________________
Date ____________________
This document is intended to provide information on the capacity, skill and experience of the Respondent.
Applicants may supplement information requested with additional sheets, if required. Pre-qualification form
should be the basis of the submission.
1.0 COMPANY PROFILE
1.1
Submitted by:
Firm name:___________________________________________________________________________________________
Address:_____________________________________________________________________________________________
______________________________________________________________________________________________________
Phone:______________________________________Fax:______________________________________________________
E-mail: ______________________________________HST #:___________________________________________________
Contact for proposal purposes ________________________________________________________________________
Description of business services ________________________________________________________________________
Total number of employees
Estimated manufacturing duration
Location of closest office to Surrey, BC_____________________________________________________________
1.2
Legal Structure of Respondent:
Year Established:
Total Years supplying/installing AV components:
□Joint Venture □Corporation □Partnership □Registered □Sole Proprietor □Other
Names and Titles of Officers, Partners, Principal:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
1.3
List and provide copies of all international, Canadian Federal and BC Provincial current valid
licenses and certifications relevant to the manufacture, supply and installation AV components. ie:, CSQ/
ISO for testing, inspection and overall quality, TUV for weather durability, Journeyman’s certification for
installation. Vancouver is a HIGH precipitation climate.
License/ Certification No.
Description of License/ Certification
Expiry Date
Applicable to Manufacturer
Applicable to Installer
COMMENT ON COMPANY MANUFACTURING QUALITY MANDATE
COMMENT ON IMPORTANCE OF CERTIFICATIONS NOTED IN END PRODUCT QUALITY
1.4
Provide a list of subcontractors that would be utilized for this project.
Name of Company (sub-trade)
Trade: License No.
2.0 FINANCIAL BACKGROUND
2.1.
Financial References
a) Bank
Name:_________________________________________________________________________________________________
Location:_______________________________________________________________________________________________
Contact:_______________________________________________________________________________________________
Phone:_________________________________________Fax:____________________________________________________
Email:__________________________________________________________________________________________________
b) Insurer
Company:_____________________________________________________________________________________________
Location:______________________________________________________________________________________________
Contact:_______________________________________________________________________________________________
Phone:______________________________________ Fax:______________________________________________________
E-mail:_________________________________________________________________________________________________
2.2
Insurance
List the following Insurance coverage amounts:
General Liability $______________________________________________________________________________________
Workers Compensation/Employers Liability $__________________________________________________________
Automobile Liability $ __________________________________________________________________________________
Professional Liability $___________________________________________________________________________________
Insurance Company ___________________________________________________________________________________
Broker/Agent __________________________________________________________________________________________
Agent Contact ______________________________________________ Tel: ______________________________________
2.3
Approximate value of audio visual contracts completed in each of the last five years:
Year 1 $_____________________ Year 2 $______________________ Year 3 $______________________
Year 4 $_____________________ Year 5 (Most recent year) $_________________________
3.0 EXPERIENCE – PEOPLE
3.1
Key manufacturer staff available for this project:
Name:____________________________ Position:______________________ Period Employed:_____________________
Name:____________________________ Position:______________________ Period Employed:_____________________
Name:____________________________ Position:______________________ Period Employed:_____________________
Name:____________________________ Position:______________________ Period Employed:____________________
3.2
Key installer staff available for this project:
Name:___________________________ Position:______________________ Period Employed:______________________
Name:___________________________ Position:______________________ Period Employed:______________________
Name:___________________________ Position:______________________ Period Employed:______________________
Name:___________________________ Position:______________________ Period Employed:______________________
4.0 EXPERIENCE – RESPONDENT FIRM
4.1
Principal audio visual projects completed over the last five years including completed project
references:
Project Title
Project Location
________________________________________________________________________________________________________
Date Completed
Contract Value
_____________________________________________________________________________________________________
Owner Contact
Owner Phone
________________________________________________________________________________________________________
Owner E-mail
Project size
________________________________________________________________________________________________________
Consultant Contact
________________________________________________________________________________________________________
Project Title
Project Location
________________________________________________________________________________________________________
Date Completed
Contract Value
_____________________________________________________________________________________________________
Owner Contact
Owner Phone
________________________________________________________________________________________________________
Owner E-mail
Project Size
________________________________________________________________________________________________________
Consultant Contact
________________________________________________________________________________________________________
Project Title
Project Location
________________________________________________________________________________________________________
Date Completed
Contract Value
_____________________________________________________________________________________________________
Owner Contact
Owner Phone
________________________________________________________________________________________________________
Owner E-mail
Project Size
________________________________________________________________________________________________________
Consultant Contact
________________________________________________________________________________________________________
Project Title
Project Location
________________________________________________________________________________________________________
Date Completed
Contract Value
_____________________________________________________________________________________________________
Owner Contact
Owner Phone
________________________________________________________________________________________________________
Owner E-mail
Project Size
________________________________________________________________________________________________________
Consultant Contact
________________________________________________________________________________________________________
Project Title
Project Location
________________________________________________________________________________________________________
Date Completed
Contract Value
_____________________________________________________________________________________________________
Owner Contact
Owner Phone
________________________________________________________________________________________________________
Owner E-mail
Project Size
________________________________________________________________________________________________________
Consultant Contact
________________________________________________________________________________________________________
Project Title
Project Location
________________________________________________________________________________________________________
Date Completed
Contract Value
_____________________________________________________________________________________________________
Owner Contact
Owner Phone
________________________________________________________________________________________________________
Owner E-mail
Project Size
________________________________________________________________________________________________________
Consultant Contact
________________________________________________________________________________________________________
4.2
Principal audio visual projects currently in progress including completed project references:
Project Title
Project Location
________________________________________________________________________________________________________
Date Completed
Contract Value
_____________________________________________________________________________________________________
Owner Contact
Owner Phone
________________________________________________________________________________________________________
Owner E-mail
Project Size
________________________________________________________________________________________________________
Consultant Contact
________________________________________________________________________________________________________
Project Title
Project Location
________________________________________________________________________________________________________
Date Completed
Contract Value
_____________________________________________________________________________________________________
Owner Contact
Owner Phone
________________________________________________________________________________________________________
Owner E-mail
Project Size
________________________________________________________________________________________________________
Consultant Contact
________________________________________________________________________________________________________
Project Title
Project Location
________________________________________________________________________________________________________
Date Completed
Contract Value
_____________________________________________________________________________________________________
Owner Contact
Owner Phone
________________________________________________________________________________________________________
Owner E-mail
Project Size
________________________________________________________________________________________________________
Consultant Contact
________________________________________________________________________________________________________
Project Title
Project Location
________________________________________________________________________________________________________
Date Completed
Contract Value
_____________________________________________________________________________________________________
Owner Contact
Owner Phone
________________________________________________________________________________________________________
Owner E-mail
Project Size
________________________________________________________________________________________________________
Consultant Contact
________________________________________________________________________________________________________
5.0 HEALTH & SAFETY
5.1
Identify any areas in which your company or staff have been cited or charged for non-compliance
within the last five years in the areas of licensing, qualification, agreements or Health and Safety. Please
provide details of these events in the space provided or as an attachment:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
6.0 VALUE-ADD
6.1
Outline any competitive advantages of your firm such as improved timelines, technical support
services, warrantee, technical support, etc.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
6.2
Briefly describe your company’s standards and associated process with respect to response time
regarding resolution of service issues. This includes but is not limited to technical support, warranty claims,
non-conformance, and order placement issues.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
7.0 RFQ SUBMITTALS
6.1
ITEM#
The following documents should accompany the respondents Qualification Response Form. Please
initial beside each item included to confirm it is included in this submission.
QUALIFICATION SUBMITTAL
Copy of current International, Federal, Provincial government, association
certifications and or trade licenses relevant to audio visual supply/ installation as
noted in section 1.3 of this appendix. Covering manufacturing, testing,
installation etc.
INCLUDED
A certificate of insurance from the Insurance Agent confirming a minimum of
$5,000,000.00 each for Comprehensive Liability and Property Damage Insurance
coverage per occurrence
Worksafe BC clearance letter and experience rating calculations indicating the
firm's injury frequency over the last three years as well as proof of no health and
safety convictions within the last three years.
A copy of respondents Health and Safety Policy.
City of Surrey Business License
A letter from respondent’s bank detailing number of years of association,
consistency of payment record, and general evidence of account in good
standing.
ACKNOWLEDGMENT
I declare that the information provided herein is true and accurate.
______________________________________________
Authorized Signature
_______________________________________________
Name
_______________________________________________
Title
________________________________________________
Date
Affix corporate seal if an incorporated company.
SEAL