(include with SOQ Section 1)

FORM AOR

ACKNOWLEDGMENT OF RECEIPT OF RTQ, ADDENDA AND RESPONSES TO QUESTIONS & CLARIFICATIONS RECEIVED

(to be attached to SOQ Section 1 Cover Letter)

NAME OFCONTRACTOR (OR JOINT VENTURE OR PARTNERSHIP)

Weherebyacknowledgereceiptof the Major Bridge Rehabilitation Project, Region 1RTQ dated September 10, 2012andsubsequent responses toquestions and Addenda issued by the Department, as listed below.

Add additional lines in tables below, if needed.

Addendum number: / Date issued by NYSDOT:
Responses to questions number: / Date issued by NYSDOT:
SIGNED
DATE
NAME
(printed or typed)
TITLE

(include with SOQ – Section 2)

FORM L

CONTRACTOR’S ORGANIZATION INFORMATION

NAME OF CONTRACTOR (OR JOINT VENTURE OR PARTNERSHIP)
Main office and contact details of Contractor
Main office address: / Contact name
Title
Telephone No.
Email
Local or regional contact details of Contractor(if different from above)
Local/regional office address: / Contact name
Title
Telephone No.
Email
NAME(S) OF CONTRACTOR ENTITY(IES) Insert more rows below if needed
Contractor Entity / Name of firm / Address / Telephone / Fax / State of Incorporation / Lead participant % equity share
PRINCIPAL PARTICIPANTS
The Department will entertain requests for prequalification from joint ventures. If a joint venture is prequalified to submit bids, or if two or more entities separately prequalified to bid elect to submit a bid as a joint venture, all participants in the joint venture shall be bound jointly and severally and each participant shall execute the bid. If the Contractor cannot demonstrate that it meets all of the referenced qualifications, than the Contractor may with others form a joint venture and request that the joint venture be deemed to be the Contractor (i.e. members of the joint venture may meet the qualification requirement collectively).

(include with SOQ - Section 4)

FORM E

PROJECT DESCRIPTION

Complete a copy of Form E for each prior project to be described. Do not alter the Form. Do not include photographs or links to external web sites. All information must be contained on the single page Form.

Contractor (or Joint Venture or Partnership)
Principal Participant:
Other (describe):
Bridge Experience (years)
DESCRIPTION OF PRIOR PROJECT
Name of project
Location
Brief description
Nature of work for which Contractor was responsible
Brief description of site conditions
Client details
(owner / agency/ contractor etc) / Client Name
Address
Contact name
Telephone
Contract Reference #
Contract value: (US$) / Final value (US$):
% of total work done by Contractor: / Commencement date:

Indicate which of the five Criteria stated in Section 3.2.4 of the RTQ this project meets:

__ 1.

__ 2.

__ 3

__ 4

__(a)

__(b)

__(c)

__ 5

(include with SOQ – Section 5)

FORM PP

PAST PERFORMANCE

For each firm, complete a copy of Form PP (all tables). Insert additional rows to any table below, if needed.

Form PP Table 1 TERMINATION FOR CAUSE / FAILURE TO COMPLETE
Has your firm ever been terminated for cause, or failed to complete any construction contract awarded it?
 Yes  No (if yes, complete project information below)
NAME OF CONTRACTOR
(OR JOINT VENTURE OR PARTNERSHIP)
Project name / Description of reason
for termination or failure to complete / Contract Bid Value / Current owner details:
Contact Name/Phone/Email
Form PP Table 2 DISCIPLINARY ACTION
NAME OF CONTRACTOR
(OR JOINT VENTURE OR PARTNERSHIP)
Project name / Description of action taken / Current owner details:
Contact Name/Phone/Email

(include with SOQ – Section 5)

FORM S

SAFETY QUESTIONNAIRE

A copy of Form S Table 1 shall be completed for each firm.

Form S SAFETY QUESTIONNAIRE FOR EACH FIRM
NAME OF CONTRACTOR(OR JOINT VENTURE OR PARTNERSHIP)
Provide the following information for the past 3 years: / 2009 / 2010 / 2011
Total number of employee hours worked (hours)
Do not include non-work time, even though paid.
Number of lost workday cases (number)
Number of restricted workday cases (number)
Number of cases with medical attention only (number)
Number of fatalities (number)
Experience Modification Rate (EMR)*
Experience Modification Rate, (number)
EMR 3 year average (’09 + ’10 + ’11)/3 : ______
The Contractor, or each venture member, must include with Section 5 of the SOQ a copy of the Experience Modification Rate (EMR) as a measure of the Contractors safety record. If the rate exceeds 1.2 for the average of the three year period provided, a written explanation shall be provided. For Contractors that do not have an EMR, due to work experience outside the US, a frequency rate table or accident incident rate or similar statistics shall be provided indicating the safety record over the last five years.

A EMR 3 year Avg. greater than or equal to 1.2 without acceptable justification, as determined solely by the Department, shall be deemed FAIL.

(include with SOQ – Section 5)

FORM DBE

RECORD OF DBE PERFORMANCE

A copy of this Form DBE shall be completed by the Contractor, or each Principal Participant of a joint venture. The term “firm” includes any Affiliate including parent companies and subsidiary companies.

Form DBE RECORD OF DBE PERFORMANCE
NAME OF CONTRACTOR(OR JOINT VENTURE OR PARTNERSHIP)
Have you ever done a project where you have not met the Project DBE Commitment and your Good Faith Effort was not accepted?
 Yes  No (if yes, complete information below)
PROJECT NAME / Explanation / Current Owner Contact
(Name/ Telephone / Email)

(Optional form to include with SOQ)

FORM RTQ-C

QUESTION REQUEST BY CONTRACTOR

Insert additional rows, if needed.

CONTRACTOR (OR JOINT VENTURE OR PARTNERSHIP)
Date sent to Agencies
REFERENCE
(e.g. RTQ section, appendix, amendment, etc) / QUESTION / (Reserved for reply process:
do not type here)
DETAILS OF QUESTIONER
SENDER’S NAME
ADDRESS
TELEPHONE
EMAIL

1

NYSDOT Region 1, Major Bridge Rehabilitation Projects > $75 million Construction Cost Estimate.