PROSPECTIVE OFFEROR’S
PRE-QUALIFICATION STATEMENT
NAME OF PROJECT & ESTIMATED CONSTRUCTION VALUE
Alliance Academy for Innovation of Cumming-Forsyth
Construction Value: $34,000,000
NAME OF OWNER:
Forsyth County Board of Education, (“Owner”)
NAME OF PROSPECTIVE
OFFEROR:
(the “Contractor”)
(Insert Legal Name of Prospective Offeror)
NOTE TO CONTRACTOR:
The criteria for prequalification (“Criteria”) are all of the items and information set forth or
requested in this form, together with any information disclosed by any of those references,
persons or entities identified in any response that is reasonably related to the Project or the
quality of work. If the response to a particular item may result in disqualification per se, the item
is so noted. The Owner, in its reasonable discretion, shall rate the Contractor in respect of each
section of this form as satisfactory or unsatisfactory. A satisfactory rating shall mean only that
the Owner believes that Contractor meets a minimum threshold with respect to being qualified to
submit a proposal on this Project only, and shall not be deemed or construed otherwise or for any
other purpose. In order to be qualified, the Contractor must not be disqualified per se, and must
not receive an unsatisfactory rating for any section. As noted at Section IX, the failure to fully
respond to all items will result in disqualification. If the answer to any item is “none” or “not
applicable,” do not leave it blank, but state “none,” or “not applicable.”
I.
INSTRUCTIONS, WARRANTIES AND ACKNOWLEDGEMENTS
A.
Each response shall be full and complete, without exception.
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B.
By submitting this Prequalification Statement, the Contractor authorizes the Owner, and
the Owner’s agents, attorneys and other representatives, to contact each and every
identified reference, person or entity. The Contractor agrees that any information
concerning the Contractor in possession of any identified reference, person or entity may
be fully disclosed, and made available, to the Owner and its agents, attorneys and other
representatives.
C.
The Contractor represents, warrants and affirms that truthful, complete and correct
information is provided to the Owner in this Prequalification Statement. In the event that
any information or other response contained herein changes in any way after submission
of this Prequalification Statement and before the contract is awarded and signed by all
parties, Contractor shall immediately notify the Owner, in writing, of such change or
changes and the Owner may take such action thereon as it deems appropriate. The
Contractor acknowledges and agrees that the Owner will rely on the truthfulness,
completeness and correctness of the information and responses contained in this
Prequalification Statement. The Contractor acknowledges and agrees that all responses
by the Contractor contained in this Prequalification Statement are material and important
to the Owner’s evaluation of the Contractor’s qualifications to undertake the Project. If
the Contractor knowingly provides any false, incorrect, misleading or incomplete
information to the Owner in this Prequalification Statement, the Contractor may be
disqualified per se to submit a proposal on this Project, or if discovered after contract
award, any agreement that is entered into between the Owner and the Contractor based on
this Prequalification Statement shall be deemed materially breached and subject to
immediate termination for cause or rescission for cause by the Owner at the sole option of
the Owner. The Owner also shall have and retain any and all other rights and remedies
provided by law, in contract or otherwise.
D.
Neither this Prequalification Statement, nor its completion by the Contractor, nor its
submission by the Contractor, nor its receipt or use by the Owner, shall give rise to any
responsibility or liability on the part of the Owner to the Contractor or to any third-party.
II.
GENERAL
A.
State the full legal name, type of legal entity (e.g., corporation, partnership,
proprietorship, etc.), state of formation or organization (if the entity is other than a
proprietorship), current address, phone number, fax number, and email address of the
Contractor contact;
2
B.
Is the Contractor a non-resident contractor within the meaning of Article 2 of Chapter 13
of Title 48 of the Official Code of Georgia Annotated?
Yes
C.
No
If the answer to II.B. is yes, is the Contractor registered in accordance with Article 2 of
Chapter 13 of Title 48 of the Official Code of Georgia Annotated?
Yes
No
N/A
PER SE CRITERION: If the answer to II.B is “yes,” then a “no” answer to II.C
shall disqualify the Contractor per se.
D.
State any previous name(s) (including aliases, d/b/a’s, and predecessor entities)
and previous address (es) of Contractor if used within the last ten (10) years (if none, state
“none”):
E.
State the full name of the Contractor’s current and predecessor president or chief
executive officer:
Current:__________________________________; since ________________________
Predecessor: ______________________________; from __________ to ___________
F.
Is the Contractor licensed, or has applied for a license, in the State of Georgia?
Yes
G.
No
State the number of Contractor’s employees both full time and, separately, part time:
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H.
State the name(s) and address(es) of all current affiliated business entities (including all
direct or indirect parents, subsidiaries, divisions) and, as to each, state the nature of
Contractor’s relationship:
I.
State the name(s) and address(es) of all former affiliated business entities (including all
direct or indirect parents, subsidiaries, divisions) and, as to each, state the nature of
Contractor’s former relationship (applicable only to last ten (10) years):
J.
State the name(s) and address(es) of all current directors and officers of the Contractor:
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THIS SECTION FOR OWNER’S USE ONLY: In respect of Section II, rate the Contractor as
“Satisfactory” or “Unsatisfactory” as a candidate for the Project. If “Unsatisfactory” provide a
brief and succinct reason.
Satisfactory
Unsatisfactory
If applicable, reason for unsatisfactory:
III.
FINANCIAL INFORMATION NOTE: Please use this form for reporting financial information only. Do
NOT attach promotional or prospectus information.
A.
Attach audited financial statements for the past three complete years. If audited financial
statements are not available, furnish the following information:
1.
Last complete fiscal year: (fiscal year ending ________)
2.
a.
Revenues (Gross)
$__________________
b.
Expenditures (Gross)
$__________________
c.
Overhead & Admin. Cost (Gross) $__________________
d.
Profit (Gross)
$__________________
e.
Net Worth
$__________________
f.
Working Capital
$__________________
Year prior to “III.A.1” above: (fiscal year ending ________)
a.
b.
c.
d.
e.
f.
3.
Revenues (Gross)
Expenditures (Gross)
Overhead & Admin. Cost (Gross)
Profit (Gross)
Net Worth
Working Capital
$__________________
$__________________
$__________________
$__________________
$__________________
$__________________
Year prior to “III.A.2” above: (fiscal year ending ________)
a.
b.
c.
Revenues (Gross)
Expenditures (Gross)
Overhead & Admin. Cost (Gross)
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$__________________
$__________________
$__________________
d.
e.
f.
B.
Profit (Gross)
Net Worth
Working Capital
$__________________
$__________________
$__________________
Furnish the following financial information for the three fiscal quarters preceding the date
of this Prequalification Statement:
1.
Last complete quarter: (quarter year ending ________)
a.
b.
c.
d.
e.
f.
2.
$__________________
$__________________
$__________________
$__________________
$__________________
$__________________
Quarter prior to “III.B.1” above: (quarter year ending ________)
a.
b.
c.
d.
e.
f.
3.
Revenues (Gross)
Expenditures (Gross)
Overhead & Admin. Cost (Gross)
Profit (Gross)
Net Worth
Working Capital
Revenues (Gross)
Expenditures (Gross)
Overhead & Admin. Cost (Gross)
Profit (Gross)
Net Worth
Working Capital
$__________________
$__________________
$__________________
$__________________
$__________________
$__________________
Quarter prior to “III.B.2” above: (quarter year ending ________)
a.
b.
c.
d.
e.
f.
Revenues (Gross)
Expenditures (Gross)
Overhead & Admin. Cost (Gross)
Profit (Gross)
Net Worth
Working Capital
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$__________________
$__________________
$__________________
$__________________
$__________________
$__________________
C.
WORK IN PROGRESS:
1.
Furnish the total dollar value (not including disputed amounts) of work in
progress (bonded and non-bonded) for each of the four (4) fiscal quarters
preceding the date of this Prequalification Statement:
a.
Last complete quarter
(ending____________) $_________________
D.
b.
Quarter prior to “III.C.1.a” (ending____________) $_________________
c.
Quarter prior to “III.C.1.b” (ending____________) $_________________
d.
Quarter prior to “III.C.1.c” (ending____________) $_________________
AVAILABLE CREDIT:
1. State the amount and expiration date, if any, of any available unused line(s) of credit:
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2. State the name, address, contact person and telephone number of the issuer of the
line(s) of credit referenced in answer to Item III.D.1 above:
E.
BANKRUPTCIES:
1. State whether the Contractor or any of the Contractor’s current or former (within the
last ten (10) years) affiliated entities have ever (i) been a debtor, voluntarily or
involuntarily, in a bankruptcy, or (ii) made an assignment for the benefit of creditors
or consented to appointment of a trustee or receiver, or (iii) been the subject of a
receivership or other insolvency proceeding:
Yes
2.
No
State whether any majority shareholder, majority owner, majority member, or
partner of the Contractor has ever (i) been a debtor, voluntarily or involuntarily, in
bankruptcy, or (ii) made an assignment for the benefit of creditors or consented to
the appointment of a trustee or receiver or (iii) been the subject of a receivership
or other insolvency proceeding:
Yes
No
PER SE CRITERION: A “Yes” Answer to either Item “III.E.1” or Item “III.E.2” shall
disqualify the Contractor per se.
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F.
LOANS:
1.
State whether the Contractor is in material default, or any declared default, on any
loan agreement or financing agreement with any bank, financial institution or
other entity.
Yes
2.
No
State whether the Contractor has in the past five (5) years materially defaulted, or
been declared in any default, on any loan agreement or financing agreement with
any bank, financial institution or other entity.
Yes
No
PER SE CRITERION: A “Yes” answer to either Item “III.F.1” or Item
“III.F.2” shall disqualify the Contractor per se.
G.
BONDING:
1.
Identify the Contractor’s surety or sureties:
PER SE CRITERION: To avoid disqualification per se, the Contractor’s surety
or sureties must be licensed in Georgia, be currently rated A+ or A or better by
A.M. Best Company and, additionally, shall be currently listed on the U.S.
Department of Treasury’s Listing of Approved Sureties (Department Circular
570) as a surety authorized to write bonds for the U.S. Government with a total
underwriting limitation of the Contractor’s surety or sureties equal to or greater
than the Estimated Construction Value for the project/projects the Contractor
selected on page one of this form.
2.
Provide written verification from the Contractor’s surety (or sureties) or surety
agent(s) of the Contractor’s current per project bonding capacity.
Per project: $__________________________
PER SE CRITERION: To avoid disqualification per se, the Contractor’s current
bonding capacity per project must equal or exceed the Estimated Construction
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Value for the Project of $34,000,000.
3. Provide written verification from the Contractor’s surety (or sureties) or surety
agent(s) the unused amount of the line of bonding credit (aggregate) currently
available to the Contractor: $_______________________
PER SE CRITERION: To avoid disqualification per se, the Contractor’s unused
bonding capacity must be not less than $136,000,000. (Four (4) times Project
Value)
4.
State the name(s), address (es), and telephone number(s) of the Contractor’s
surety agent(s) or underwriting contact(s) for the past five (5) years:
Current
____________________________________________________________
____________________________________________________________
____________________________________________________________
One year ago
_______________________________________________________
____________________________________________________________
____________________________________________________________
Two years ago
______________________________________________________
____________________________________________________________
____________________________________________________________
Three years ago
_____________________________________________________
____________________________________________________________
____________________________________________________________
5.
State whether performance or payment bond claims have been made to the
Contractor’s surety on any project within the past five (5) years:
Yes
No
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6.
If the answer to the preceding Item “III.G.5” is “yes,” describe each claim, the
name of the project, the owner, the name of the company or person making each
claim, the date of each claim, the circumstances of each claim, and the resolution
of each claim:
7.
State whether any surety has refused to bond the Contractor on any project in the
past five years. If the answer is “yes,” state the name of the project and specify
the reasons given for each refusal, the date of each refusal, and the name and
address of the surety that refused to bond:
Yes
No
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8.
State whether any surety has refused to bond the Contractor’s affiliated entities on
any project in the past five years. If the answer is “yes,” state the name of the
project and specify the reasons given for each refusal, the date of each refusal, and
the name of the surety that refused to bond:
Yes
H.
No
MERGERS AND ACQUISITIONS
1.
State whether the Contractor has been acquired or been a party to a merger within
the preceding three years. If the answer is “yes,” identify all parties to such
acquisition or merger, provide the date of the acquisition or merger, the reasons
for the acquisition or merger, and a brief description of the transaction:
Yes
No
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2.
State whether the Contractor has acquired any other companies or entities in the
preceding three years. If the answer is “yes,” identify all companies or entities
acquired, provide the date of acquisition, the reasons for the acquisition, and a
brief description of the business of the company or entity acquired:
Yes
No
THIS SECTION FOR OWNER’S USE ONLY: In respect of Section III, rate the Contractor as
“Satisfactory” or “Unsatisfactory” as a candidate for the Project. If “Unsatisfactory” provide a
brief and succinct reason.
Satisfactory
Unsatisfactory
If applicable, reason for unsatisfactory:
IV.
CONTRACTOR EXPERIENCE - SIMILAR PROJECTS
A. (1) Identify all similar projects constructed by the Contractor in the last five years, of
construction value equal to or greater than twenty-three million dollars
($23,000,000.00), specifying the Project, construction value, name, date durations,
address, telephone number, email address and contact person of each owner and
architect of each of those projects. Also specify if project contract was Construction
Management at Risk or General Contractor:
13
PER SE CRITERION: If the response to item “IV.A, 1” is “none,” the Contractor will
be disqualified per se from that corresponding project/projects.
B.
State the following information for each project on which, and each owner for which, the
Contractor has completed in the last two years:
Name: ________________________
Location:_______________________
Contract Price: ______________________ Owner:_________________________
Address:
_______________________ City/State:______________________
Contact: ___________________________ Phone: ________________________
Arch/Eng:
______________________
Substantial completion on time? Yes
Contact/Phone:___________________
No
Name: ________________________
Location:_______________________
Contract Price: ______________________ Owner:_________________________
Address:
_______________________ City/State:______________________
Contact: ___________________________ Phone: ________________________
Arch/Eng:
______________________
Substantial completion on time? Yes
No
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Contact/Phone:___________________
Name: ________________________
Location:_______________________
Contract Price: ______________________ Owner:_________________________
Address:
_______________________ City/State:______________________
Contact: ___________________________ Phone: ________________________
Arch/Eng:
______________________
Substantial completion on time? Yes
Contact/Phone:___________________
No
Name: ________________________
Location:_______________________
Contract Price: ______________________ Owner:_________________________
Address:
_______________________ City/State:______________________
Contact: ___________________________ Phone: ________________________
Arch/Eng:
______________________
Substantial completion on time? Yes
No
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Contact/Phone:___________________
Name: ________________________
Location:_______________________
Contract Price: ______________________ Owner:_________________________
Address:
_______________________ City/State:______________________
Contact: ___________________________ Phone: ________________________
Arch/Eng:
______________________
Substantial completion on time? Yes
Contact/Phone:___________________
No
Name: ________________________
Location:_______________________
Contract Price: ______________________ Owner:_________________________
Address:
_______________________ City/State:______________________
Contact: ___________________________ Phone: ________________________
Arch/Eng:
______________________
Substantial completion on time? Yes
No
16
Contact/Phone:___________________
Name: ________________________
Location:_______________________
Contract Price: ______________________ Owner:_________________________
Address:
_______________________ City/State:______________________
Contact: ___________________________ Phone: ________________________
Arch/Eng:
______________________
Substantial completion on time? Yes
Contact/Phone:___________________
No
Name: ________________________
Location:_______________________
Contract Price: ______________________ Owner:_________________________
Address:
_______________________ City/State:______________________
Contact: ___________________________ Phone: ________________________
Arch/Eng:
______________________
Substantial completion on time? Yes
No
17
Contact/Phone:___________________
Name: ________________________
Location:_______________________
Contract Price: ______________________ Owner:_________________________
Address:
_______________________ City/State:______________________
Contact: ___________________________ Phone: ________________________
Arch/Eng:
______________________
Substantial completion on time? Yes
Contact/Phone:___________________
No
Name: ________________________
Location:_______________________
Contract Price: ______________________ Owner:_________________________
Address:
_______________________ City/State:______________________
Contact: ___________________________ Phone: ________________________
Arch/Eng:
______________________
Substantial completion on time? Yes
No
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Contact/Phone:___________________
If “No” was answered to any of the “substantial completion on time” questions in IV.B. above,
please describe below.
C.
State whether the Contractor has ever defaulted, or has ever been declared in default, on
any project. If the answer is “yes,” identify below each project, the name of the owner,
the date, and the circumstances of the default:
Yes
No
19
D.
State whether the Contractor has ever had liquidated damages assessed. If the answer is
“yes,” identify below each project, the name of the owner, the date, and the circumstances
resulting in liquidated damages being assessed:
Yes
No
THIS SECTION FOR OWNER’S USE ONLY: In respect of Section IV, rate the Contractor as
“Satisfactory” or “Unsatisfactory” as a candidate for the Project. If “Unsatisfactory” provide a
brief and succinct reason.
Satisfactory
Unsatisfactory
If applicable, reason for unsatisfactory:
20
V.
LEGAL PROCEEDINGS
A.
ARBITRATIONS:
Identify below all construction arbitration demands filed by, or against, the Contractor in
the last five years, and describe the nature of the claim, the amount in dispute, the parties,
the case number, the location, and the ultimate resolution of the arbitration:
21
B.
LAWSUITS:
Identify below all lawsuits, other than labor or personal injury litigation, filed by, or
against, the Contractor in the last five years, and describe the nature of the claim, the
amount in dispute, the parties, the case number, the Court and the ultimate resolution of
the lawsuit:
22
C.
OTHER PROCEEDINGS:
1.
Identify below any lawsuits, administrative proceedings, or hearings initiated by
the national labor relations board or any similar state agency in the past five years
concerning any labor practices of the Contractor, and describe the nature of the
proceeding and ultimate resolution:
23
2.
Identify below any lawsuits, administrative proceedings, or hearings initiated, or
fines assessed, by the occupational safety and health administration concerning
the project safety practices of the Contractor in the last five years, and describe the
nature of any proceeding and ultimate resolution:
24
3.
Identify below any lawsuits, administrative proceedings, investigations, or
hearings initiated by the internal revenue service, or any state revenue department,
concerning the tax liability of the Contractor, other than audits, in the last five
years, and describe the nature of any proceeding and ultimate resolution:
25
4.
Identify below any other proceedings or hearings initiated, or fines assessed, by
any local, state or federal entity or agency concerning the Contractor in the last
five years, and describe the nature of any proceeding and its ultimate resolution:
26
5.
State whether any criminal proceedings or investigations have been brought
against the Contractor in the last ten years. If the answer is “yes,” describe below:
Yes
No
THIS SECTION FOR OWNER’S USE ONLY: In respect of Section V, rate the Contractor as
“Satisfactory” or “Unsatisfactory” as a candidate for the Project. If “Unsatisfactory” provide a
brief and succinct reason.
Satisfactory
Unsatisfactory
If applicable, reason for unsatisfactory:
27
VI.
REFERENCES
Unless otherwise requested, all references must be unaffiliated with the Contractor, and
must be current, having done business with the Contractor in the preceding twelve
months. Provide all requested references. In addition to the references requested below,
the Contractor acknowledges that any owner, architect, or other person or entity identified
in this Prequalification Statement may be contacted as a reference.
A.
BANKS:
Bank #1
Name:
______________________________________________
Address:
_____________________________________________
Contact:
_____________________________________________
City/State:
_____________________________________________
Phone:
_______________________
Bank #2
Name:
_____________________________________________
Address:
_____________________________________________
Contact:
_____________________________________________
City/State:_____________________________
Phone:
__________________________
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THIS SECTION FOR OWNER’S USE ONLY: In respect of Section VI, rate the Contractor as
“Satisfactory” or “Unsatisfactory” as a candidate for the Project. If “Unsatisfactory” provide a
brief and succinct reason.
Satisfactory
Unsatisfactory
If applicable, reason for unsatisfactory:
VII.
CURRENT WORK ON HAND
List below all current work on hand:
Name of Project:________________________________________________________________
Contract Amount:_____________________ Scheduled Completion: _____________________
Description of Project: ___________________________________________________________
Contact:
Name:_____________________________ Phone #:_____________________________
Address:________________________________________________________________
Lead Design Professional:
Name:_____________________________ Phone #:_____________________________
Address:________________________________________________________________
Current Status:_________________________________________________________________
Name of Project:________________________________________________________________
29
Contract Amount:_____________________ Scheduled Completion: _____________________
Description of Project: ___________________________________________________________
Contact:
Name:_____________________________ Phone #:_____________________________
Address:________________________________________________________________
Lead Design Professional:
Name:_____________________________ Phone #:_____________________________
Address:________________________________________________________________
Current Status:_________________________________________________________________
Name of Project:________________________________________________________________
Contract Amount:_____________________ Scheduled Completion: _____________________
Description of Project: ___________________________________________________________
Contact:
Name:_____________________________ Phone #:_____________________________
Address:________________________________________________________________
Lead Design Professional:
Name:_____________________________ Phone #:_____________________________
Address:________________________________________________________________
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Current Status:_________________________________________________________________
Name of Project:________________________________________________________________
Contract Amount:_____________________ Scheduled Completion: _____________________
Description of Project: ___________________________________________________________
Contact:
Name:_____________________________ Phone #:_____________________________
Address:________________________________________________________________
Lead Design Professional:
Name:_____________________________ Phone #:_____________________________
Address:________________________________________________________________
Current Status:_________________________________________________________________
Name of Project:________________________________________________________________
Contract Amount:_____________________ Scheduled Completion: _____________________
Description of Project: ___________________________________________________________
Contact:
Name:_____________________________ Phone #:_____________________________
Address:________________________________________________________________
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Lead Design Professional:
Name:_____________________________ Phone #:_____________________________
Address:________________________________________________________________
Current Status:_________________________________________________________________
Name of Project:________________________________________________________________
Contract Amount:_____________________ Scheduled Completion: _____________________
Description of Project: ___________________________________________________________
Contact:
Name:_____________________________ Phone #:_____________________________
Address:________________________________________________________________
Lead Design Professional:
Name:_____________________________ Phone #:_____________________________
Address:________________________________________________________________
Current Status:_________________________________________________________________
Name of Project:________________________________________________________________
Contract Amount:_____________________ Scheduled Completion: _____________________
32
Description of Project: ___________________________________________________________
Contact:
Name:_____________________________ Phone #:_____________________________
Address:________________________________________________________________
Lead Design Professional:
Name:_____________________________ Phone #:_____________________________
Address:________________________________________________________________
Current Status:_________________________________________________________________
Name of Project:________________________________________________________________
Contract Amount:_____________________ Scheduled Completion: _____________________
Description of Project: ___________________________________________________________
Contact:
Name:_____________________________ Phone #:_____________________________
Address:________________________________________________________________
Lead Design Professional:
Name:_____________________________ Phone #:_____________________________
33
Address:________________________________________________________________
Current Status:_________________________________________________________________
Name of Project:________________________________________________________________
Contract Amount:_____________________ Scheduled Completion: _____________________
Description of Project: ___________________________________________________________
Contact:
Name:_____________________________ Phone #:_____________________________
Address:________________________________________________________________
Lead Design Professional:
Name:_____________________________ Phone #:_____________________________
Address:________________________________________________________________
Current Status:_________________________________________________________________
Name of Project:________________________________________________________________
Contract Amount:_____________________ Scheduled Completion: _____________________
Description of Project: ___________________________________________________________
Contact:
Name:_____________________________ Phone #:_____________________________
34
Address:________________________________________________________________
Lead Design Professional:
Name:_____________________________ Phone #:_____________________________
Address:________________________________________________________________
Current Status:_________________________________________________________________
Name of Project:________________________________________________________________
Contract Amount:_____________________ Scheduled Completion: _____________________
Description of Project: ___________________________________________________________
Contact:
Name:_____________________________ Phone #:_____________________________
Address:________________________________________________________________
Lead Design Professional:
Name:_____________________________ Phone #:_____________________________
Address:________________________________________________________________
Current Status:_________________________________________________________________
Name of Project:________________________________________________________________
35
Contract Amount:_____________________ Scheduled Completion: _____________________
Description of Project: ___________________________________________________________
Contact:
Name:_____________________________ Phone #:_____________________________
Address:________________________________________________________________
Lead Design Professional:
Name:_____________________________ Phone #:_____________________________
Address:________________________________________________________________
Current Status:_________________________________________________________________
THIS SECTION FOR OWNER’S USE ONLY: In respect of Section VIII, rate the Contractor
as “Satisfactory” or “Unsatisfactory” as a candidate for the Project. If “Unsatisfactory” provide
a brief and succinct reason.
Satisfactory
Unsatisfactory
If applicable, reason for unsatisfactory:
36
VIII. REPRESENTATIONS
Have you furnished all of the information and representations requested herein?
Yes
No
PER SE CRITERION:
se.
IX.
A “No” answer to “VIII” shall disqualify the Contractor per
CONTRACTOR’S CERTIFICATION
I certify to the Owner that the information and responses provided in this Prequalification
Statement are true, correct and complete. The Owner may rely on the information provided in
this Prequalification Statement. The Owner, or the Owner’s designated representative, may
contact any person, entity or reference identified in this Prequalification Statement. Each person,
entity or reference may make any information concerning the Contractor available to the Owner
or the Owner’s designated representative.
Dated __________________________, 20__.
CONTRACTOR:
By:_________________________________
Printed Name:
Title:_______________________________
Date:_______________________________
Sworn to and subscribed
before me this ______ day
of _______________, 20__.
_________________________
Notary Public
My Commission Expires:
37