FORMA
SOQTRANSMITTALLETTER
Offeror Name:
SOQ Date:
VirginiaDepartmentofTransportation
OfficeofPublic-PrivatePartnerships
1401 EastBroadStreet,Suite1306
Richmond,Virginia23219
Attn:MortezaFarajian,Ph.D.
Theundersigned(“Offeror”)submitsthisStatementofQualifications(“SOQ”)inresponseto thatcertainRequestforQualificationsdatedasofDecember 15,2017(asamended, the“RFQ”), issuedbytheVirginiaDepartmentofTransportation(“theDepartment”)todelivertheI-64
HamptonRoadsBridge-Tunnel ExpansionProject(the“Project”),throughaComprehensive Agreement(“CA”). Capitalized termsnototherwisedefinedhereinshallhavethemeaningsset forthintheRFQ.
Enclosed,andbythisreferenceincorporatedhereinandmadeapartofthisSOQ,arethe following:
Volume1: GeneralInformation;
Volume2: TechnicalExperienceandQualifications;and
Volume3: FinancialQualificationsandCapabilities
OfferorrepresentsandwarrantsthatithasreadtheRFQandagreestoabidebythecontentsand termsoftheRFQ andtheSOQ.
Offerorunderstands thattheDepartmentisnot boundtodeterminethat anyOfferorisa Proposer andmayrejecteachSOQtheDepartmentmayreceive.
OfferorfurtherunderstandsthatallcostsandexpensesincurredbyitinpreparingthisSOQwill bebornesolelybytheOfferor.
Offeror agrees that the Department will not be responsible for any errors, omissions, inaccuracies,orincompletestatementsinthisSOQ.
ThisSOQshallbegovernedbyandconstruedinallrespectsaccordingtothelawsofthe
Commonwealthof Virginia.
Offeror’sbusinessaddress:
(No.)(Street)(FloororSuite)
(City)(StateorProvince)(ZIP orPostalCode)(Country) StateorCountryofIncorporation/Formation/Organization:
[insertappropriatesignatureblockfromfollowingpages]
1.Samplesignatureblockfor corporationor limitedliabilitycompany:
[InsertOfferor’sname] By:
PrintName:
Title:
2.Samplesignatureblockforpartnershipor JointVenture:
[InsertOfferor’sname]
By:[Insert generalpartner’sormember’sname] By:
PrintName:
Title:
[Add signaturesofadditionalgeneralpartnersormembersas appropriate]
3.Samplesignatureblockforattorneyinfact:
[InsertOfferor’sname] By:
PrintName:
AttorneyinFact
4.Samplesignatureblockforan Offerornotyetformedas a legalentity:
[Insertleadteammemberentityname],on behalfofitself andtheotherteammembersexpectedtobe apart of [Insert Offeror’s expectedname]
By:
PrintName: Title:
FORMB ACKNOWLEDGEMENTOFRFQAND ADDENDA
Acknowledgement shallbemadeofreceiptoftheRequestforQualifications(“RFQ”)and Addendapertaining toI-64HamptonRoads-Bridge TunnelExpansionProjectissuedbythe DepartmentpriortotheStatementofQualifications(“SOQ”)duedate. Failuretoincludethis acknowledgementintheSOQ mayresultintherejectionofyourSOQ.
Bysigningthis Form B, the Offeror acknowledgesreceiptof theRFQ and the following revisionsorAddenda(ifany)totheRFQfortheabove designatedprojectwhichwereissued undercoverletter(s)ofthedate(s)shown hereon:
1. Coverletterof RFQ
(Date)
2. Coverletterof
(Date)
3. Coverletterof
(Date)
SIGNATUREDATE
PRINTED NAMETITLE
FORM C
FORMOFCONFIDENTIAL CONTENTSINDEX
Offeror Name:
PursuanttoVa.CodeAnn.§2.2-3705.6(11)(b),OfferorsmayrequesttheDepartment tokeep confidential: (i)tradesecrets;(ii)financialinformationnotgenerally availabletothepublic throughregulatorydisclosureorotherwise;or(iii)otherinformationsubmittedbyanOfferor whereifsuchinformationwasmadepublic priortotheexecutionofaninterimagreement ora comprehensive agreement, thefinancialinterestorbargainingpositionoftheOfferororthe Departmentwouldbe adverselyaffected.
Forsuchinformation tobeexcluded fromdisclosure requirementsundertheVFOIA,theOfferor mustmakeawrittenrequesttotheDepartment(bysubmitting anexecutedversionofthetable below):
(1)Invoking suchexclusionuponsubmissionofthedataorothermaterials forwhich protectionfromdisclosureissought;
(2)Identifyingwithspecificitythedataorothermaterialsforwhichprotectionis sought;and
(3)Statingthereasons whyprotectionisnecessary.
Theconfidentialmaterialsubmittedmustbeidentifiedbysomedistinctmethodwithinthebody oftheSOQsuchashighlighting orunderlining. Blanketclassificationsarenotacceptable. In accordance withVa.CodeAnn.§2.2-3705.6(11),theDepartmentwillmakeawritten determinationoftheappropriatescopeandnatureoftheprotectionaffordedtotheOfferor.
SECTION/TITLE / PAGENUMBER(S) / REASON(S) FORWITHHOLDINGFROMDISCLOSURE
By:
Title:
Date:
FORM D
SOQCONTENTSINDEX
OfferorsshallfurnishacopyofthisStatementofQualifications(“SOQ”)ContentsChecklist, withthepagereferencesadded,withtheirSOQs.
SOQComponent / Form / RFQCrossreference / SOQ
Page
Reference
Volume1–GeneralInformation
SOQTransmittalLetter / FormA / PartB,Section4.2.1(a)
AcknowledgementofRFQandAddenda / FormB / PartB,Section4.2.1(a)
ConfidentialContentsIndex / FormC / PartB,Section4.2.1(b)
SOQContentsChecklist / FormD / PartB,Section4.2.1(c)
ExecutiveSummary / -- / PartB,Section4.2.1(d)
OfferorInformation / -- / PartB,Section4.2.1(e)
InformationRegardingOfferor,LeadContractor,and
LeadDesigner (including,ifapplicable, documentation showingtheDepartment’s approvaloftheOfferor’s completedFormO(JointVentureBiddingAgreement)) / FormsE
andF / PartB,Section4.2.1(e)
LegalInformation / -- / PartB,Section4.2.1(f)
Certification / FormG / PartB,Section4.2.1(g)
SuretyLetter(s) / -- / PartB,Section4.2.1(h)
LeadContractorSafetyQualificationsForm / FormH / PartB,Section4.2.1(i)
Volume2–GeneralTechnicalQualifications
ExperienceofOfferorTeamFirms / PartB,Section4.2.2(a)
LeadContractor / FormI / PartB,Section4.2.2(a)(i)(A)
LeadDesigner / FormJ / PartB,Section4.2.2(a)(i)(B)
ProjectDescriptions / -- / PartB,Section4.2.2(a)(ii)
KeyPersonnelQualifications / PartB,Section4.2.2(a)(iv)
ResumeofProjectExecutive / FormM / AppendixC
ResumeofProjectManager / FormM / AppendixC
ResumeofConstructionManager / FormM / AppendixC
ResumeofEnvironmentalManager / FormM / AppendixC
ResumeofSafetyManager / FormM / AppendixC
ResumeofResponsibleChargeEngineer / FormM / AppendixC
ResumeofDesignManager / FormM / AppendixC
ResumeofQualityAssuranceManager / FormM / AppendixC
ResumeofGeotechnicalManager / FormM / AppendixC
SOQComponent / Form / RFQ
Crossreference / SOQ
Page
Reference
KeyPersonnelCommitment / FormN / PartB,Section4.2.2(a)(v)
Statementof TechnicalApproach(General) / -- / PartB,Section4.2.2(a)(vi)
TunnelDeliveryQualifications / -- / PartB,Section4.2.2(b)
ProjectExperience / -- / PartB,Section4.2.2(b)
TunnelConstructor / FormK / PartB,Section4.2.2(b)
TunnelDesigner / FormL / PartB,Section4.2.2(b)
ProjectDescriptions / -- / PartB,Section4.2.2(b)
OrganizationalStructure / -- / PartB,Section4.2.2(b)
KeyPersonnel / FormM / PartB,Section4.2.2(b)
ResumeofTunnelConstructionManager / FormM / AppendixC
ResumeofLeadTunnelEngineer / FormM / AppendixC
ResumeofLeadMechanicalEngineer / FormM / AppendixC
KeyPersonnelCommitment / FormN / PartB,Section4.2.2(b)
StatementofTechnicalApproach(Tunnel) / -- / PartB,Section4.2.2(b)
Volume3– FinancialQualificationsandCapability
FinancialStatementsandCreditRatings / -- / PartB,Section4.2.3(a)
MaterialChangeinFinancialCondition / -- / PartB,Section4.2.3(b)
Off-BalanceSheetLiabilities / -- / PartB,Section4.2.3(c)
FORME
OFFERORTEAMINFORMATION (forPublicRelease)
Offeror Name:
Entity(checkoneboxforentitycompletingFormE, as applicable):
OfferorLeadContractorLeadDesigner
NameofEntityCompleting FormE:
YearEstablished:Stateof Organization:
FederalTaxID No. (ifapplicable):Telephone No.:
North AmericanIndustryClassification SystemCode (ifapplicable):
TypeofBusinessOrganization(checkone):
Corporation
Partnership
JointVenture
LimitedLiabilityCompany
Other(describe)
A.BusinessAddress:
ContactTelephoneNumber:
B.CompleteaseparateEandFormGforeachentity(Offeror,LeadContractor,orLead Designer)on Offerorteamand includeitwiththe SOQ. Inaddition,identifythenameof suchentitiesinthespacebelow.
Name
Underpenaltyofperjury,Icertifythattheforegoingistrueandcorrect,andthatIamanofficial representativeofthefirm dulyauthorizedto executedanddeliverthisFormE:
By:PrintName:Title: Date:
[Pleasemakeadditionalcopiesofthisformas needed.]
FORMF
OFFERORTEAMMEMBERAFFILIATESANDSUBSIDIARIES
ProjectName:I-64HamptonRoadsBridge-TunnelExpansionProject
Offeror Name:
AffiliatedandSubsidiaryCompaniesoftheOfferor
Offerorsshallcomplete the tableand include theaddressesofaffiliatesorsubsidiary companies, asapplicable.By completing thistable,Offerorscertify thatallaffiliatedandsubsidiary companies(affiliatedcompaniesbeing companies thatare owned at least10%by the same parent, and subsidiary companiesbeing companies thatare whollyowned bytheOfferor)oftheOfferorthatmay participatein anywayin theProjectarelisted.
TheOfferordoesnothaveany affiliatedorsubsidiary companies.Affiliatedand/orsubsidiary companiesof theOfferorarelisted below.
RelationshipwithOfferor
(AffiliateorSubsidiary) / FullLegalName / Address
FORMG CERTIFICATION
[Note:FormGshouldbecompletedbytheOfferor,theLeadContractor,eachLeadContractor
Member (ifany),and theLead Designer.]
ProjectName:I-64HamptonRoadsBridge-TunnelExpansionProject
Offeror Name:
NameofTeam Memberand Role:
1)Theundersignedcertifiesthat[NAME OFTEAM MEMBER]:
a) isnotpresently debarred,suspended,proposedfordebarment,declared ineligible,orvoluntarily excludedfromcoveredtransactionsbyanyfederaldepartmentor agency;
b) hasnot,withinathree-yearperiodprecedingthisSOQ,beenconvictedof orhadaciviljudgmentrenderedagainstitorany memberofitsexecutivemanagementteamfor commissionoffraudoracriminaloffenseinconnectionwithobtaining,attemptingtoobtain,or performingapublic(federal,state,orlocal)transactionorcontractunderatransactionwitha publicentity andhasnotbeenconvictedofanyviolationsoffederalorstateantitruststatutesor commissionofembezzlement, theft,forgery,bribery,falsification,ordestructionofrecords, makingfalsestatements,or receivingstolenproperty;
c) isnot(norisanymemberofitsexecutivemanagementteam)presently indictedfororotherwisecriminallyorcivilly chargedbyagovernmentalentity(federal,stateor local)withcommissionofanyoftheoffensesenumerated inparagraph1(b)ofthiscertification; and
d) hasnotwithinathree-yearperiodprecedingthisSOQhadoneormore transactionswithpublicentities(federal,state,orlocal)terminatedforcauseordefault.
2)WheretheOfferorteammemberisunabletocertifyanyofthestatementsinthis certification,such Offerorteammembershallattachan explanationtothisform.
Theundersignedmakestheforegoingstatementstobe filed with theSOQsubmittedonbehalfof theOfferorfor contractstobeenteredintobytheDepartment.
SignatureDateTitle
FORMH
LEADCONTRACTORSAFETYQUALIFICATIONSFORM
Company Name: / Date:NumberofEmployees:
1. Workers’ Compensation Experience Modification
Ratio (EMR) or Experience Modification Factor
(EMF)forlast3 years / 2015 / 2016 / 2017
a.List your firm’s Worker’s Compensation EMR/EMF
calculatedby NationalCouncilonCompensation Insurance,Inc.orothersimilaradvisory organizationor ratingbureau foreach ofthe last3 years.
IftheEMR/EMF isgreater than1.0foranyofthelastthreeyears,pleaseprovide anexplanation
below.
2. AccidentandIllnessStatisticsforlast3 years / 2015 / 2016 / 2017
a.Numberofman-hoursworked
b. NumberofOSHArecordableinjuries
c.OSHArecordableIncident Rate
d. Numberof losttimeaccidents
e.Lostworkdaycaserate
f.Numberoffatalities(Providedetailsforeachfatalityon
aseparatesheet)
g. Number of citations by OSHA or other regulatory
agencies(providedetailsforeachcitationonaseparate sheet)
h. Wasyourcompanycitedbyastatedepartmentoflabor
foranysafetyviolations(ListYESorNOandprovide details foreach citation onaseparatesheet)
Submita copyofOSHA300A Logsforthelast3 years
Non-U.S.companiesthat cannotprovidetherequiredOSHAand EMRrecordsshallprovideand explain equivalentsafetydataforthespecifiedthree-yearperiod.
FORMICONSTRUCTIONEXPERIENCE
EXPERIENCEOFTHELEADCONTRACTORIN THECONSTRUCTIONOFREFERENCEPROJECTS
(LimitOnePagePerProject)
a.ProjectNameLocation / b.Nameofthe primedesignconsultingfirmresponsiblefor the overallprojectdesign. / c. Contactinformationofthe Clientor
OwnerandtheirProjectManagerwhocan verify Firm’sresponsibilities. / d.Contract
Completion Date (Original) / e.Contract
CompletionDate (Actualor Estimated) / f.ProjectValue(inmillions) / g.DollarValueofwork
performedbytheFirm identifiedastheLead Contractorforthis procurement.(inmillions)
Name:
Location: / Name: / NameofClient./Owner:
Phone:
ProjectManager: Phone:
Email: / MM/YYYY / MM/YYYY
h.Narrativedescribingthework performed by thefirmidentifiedastheLead Contractorforthisprocurement.If theOfferorchooses tosubmitwork completedby an affiliatedorsubsidiarycompanyoftheLead Contractor,identifythe
fulllegalnameoftheaffiliateorsubsidiaryandtheroletheywillhaveonthisProjectsotherelevancyofthatworkcanbeconsideredaccordingly.Thisformshallincludeonlyonesingularproject.Projects/contractswith multiple phases,segments, elements(projects),and/or contractsshallnotbeconsidered asingleproject. Ifaprojectlistedincludesmultiplephases,segments, elements(projects), and/or contracts,itcannotbeclaimedasasingleproject on this form. If theOfferorchoosestosubmitwork performedasaJoint Ventureorpartnership,identifyhow theJoint Ventureorpartnershipwasstructuredandprovide adescriptionoftheportionof thework performed only by theOfferor’s firm.Inanycase,onlythefirstphase,segment,element,and/orcontractlistedwillbe evaluated.
FORMJDESIGNEXPERIENCE
EXPERIENCEOFTHELEADDESIGNERIN THEDESIGNANDENGINEERINGOFREFERENCEPROJECTS
(LimitOnePagePerProject)
a.ProjectNameLocation / b.Nameofthe prime/generalcontractorresponsibleforoverall constructionofthe project. / c. Contactinformationofthe Clientandits
ProjectManagerwhocanverifyFirm’s responsibilities. / d.Construction
Contract Completion Date (Original) / e.Construction
Contract CompletionDate (Actualor Estimated) / f.ProjectValue(inmillions) / g.DesignFee forthe work
performedbytheFirmidentified astheLeadDesignerforthis procurement.(inmillions)
Name:
Location: / Name: / NameofClient.:
Phone:
ProjectManager: Phone:
Email: / MM/YYYY / MM/YYYY
h.NarrativedescribingtheworkperformedbythefirmidentifiedastheLeadDesignerforthisprocurement.Includetheofficelocation(s)wherethedesignworkwasperformedandwhetherthefirmwastheprimedesignerora subconsultant.Thisform shallincludeonlyonesingularproject.Projects/contracts withmultiplephases,segments,elements(projects),and/orcontractsshallnotbeconsideredasingleproject.Ifaprojectlistedincludeswithmultiple phases,segments,elements(projects),and/orcontracts, it cannotbeclaimedasa singleprojectonthisform.Inanycase,onlythe firstphase,segment,element,and/orcontractlistedwillbeevaluated.
FORMKTUNNELCONSTRUCTIONEXPERIENCE
EXPERIENCEOFTHETUNNELCONSTRUCTORIN THECONSTRUCTIONOFREFERENCEPROJECTS
(LimitOnePagePerProject)
a.ProjectNameLocation / b.Nameofthe primedesignconsultingfirmresponsibleforthe designofthe tunnel. / c. Contactinformationofthe Clientor
OwnerandtheirProjectManagerwhocan verify Firm’sresponsibilities. / d.Contract
Completion Date (Original) / e.Contract
CompletionDate (Actualor Estimated) / f. ContractValue(inmillions) / g.DollarValueofwork
performedbytheFirmidentified asthe TunnelConstructorfor
this procurement(inmillions)
Name:
Location: / Name: / NameofClient./Owner:
Phone:
ProjectManager: Phone:
Email: / MM/YYYY / MM/YYYY
h.Narrativedescribingthe workperformedbythefirmidentifiedastheTunnelConstructorforthisprocurement.Ifthe Offerorchoosesto submitwork completedby anaffiliatedorsubsidiarycompanyoftheTunnelConstructor,identifythe
fulllegalnameoftheaffiliate orsubsidiary andtheroletheywillhaveon thisProjectsotherelevancyofthatworkcanbeconsidered accordingly.Thisform shallinclude onlyonesingularproject.Projects/contractswith multiplephases, segments,elements(projects),and/orcontractsshallnotbeconsidered asingleproject. Ifaprojectlistedincludesmultiplephases,segments,elements(projects),and/orcontracts,itcannotbeclaimedasasingleproject onthisform.Ifthe Offerorchooses tosubmitwork performed asaJoint Ventureorpartnership,identifyhowtheJoint Ventureorpartnershipwasstructuredandprovide adescriptionof theportionofthework performedonlyby theOfferor’sfirm. In anycase, onlythefirstphase,segment,element,and/orcontractlistedwillbeevaluated.
FORMLTUNNELDESIGNEXPERIENCE
EXPERIENCEOFTHETUNNELDESIGNERIN THEDESIGNANDENGINEERINGOFREFERENCE PROJECTS
(LimitOnePagePerProject)
a.ProjectNameLocation / b.Nameofthe prime/generalcontractorresponsiblefor constructionofthe tunnel. / c. Contactinformationofthe Clientand
theirProjectManagerwhocanverify
Firm’sresponsibilities. / d.Construction
Contract Completion Date (Original) / e.Construction
Contract CompletionDate (Actualor Estimated) / f. ContractValue(inmillions) / g.DesignFee forthe work
performedbytheFirmidentified asthe TunnelDesignerforthis procurement.(inmillions)
Name:
Location: / Name: / NameofClient.:
Phone:
ProjectManager: Phone:
Email: / MM/YYYY / MM/YYYY
h.NarrativedescribingtheworkperformedbythefirmidentifiedastheTunnelDesignerforthisprocurement.Includetheofficelocation(s)wherethedesignworkwasperformedandwhetherthefirmwastheprimedesignerora
subconsultant.Thisformshall includeonly one singularproject.Projects/contractswith multiplephases,segments,elements(projects),and/orcontractsshall notbe consideredasingleproject.Ifaprojectlisted includeswith multiplephases, segments,elements(projects),and/orcontracts, it cannotbeclaimedasa singleprojectonthisform.Inanycase,onlythefirstphase,segment,element,and/orcontractlistedwillbeevaluated.
FORMM
KEYPERSONNELRESUMEFORM
BriefResume ofKeyPersonnel for theProject.a.Name &CurrentTitle:
b.KeyPersonnelPosition onProject:
c.Name of Firmwith whichyou are nowassociated:
d.Years’experience:With this Firm ;Years WithOtherFirms Years
Pleaselistchronologically(mostrecentexperiencefirst)youremploymenthistory,position,general responsibilities,anddurationofemploymentforthelastfifteen(15)years.(NOTE:Ifyouhavelessthan
15yearsofexperience,pleaselisttheexperienceforthoseyearsyouhaveworked.Projectspecific
experience shallbe includedin Section (g) below):
e.Education:Name &Location ofInstitution(s)/Degree(s)/Year/Specialization:
f.Active Registration:Year FirstRegistered/Discipline/Virginia Registration #:
g.References
1. NameofProject:
Start/FinishDates ofProject: ReferenceName:
ReferenceEmail: ReferenceTelephone:
2. NameofProject:
Start/FinishDates ofProject: ReferenceName:
ReferenceEmail: ReferenceTelephone
3. NameofProject:
Start/FinishDates ofProject: ReferenceName:
ReferenceEmail: ReferenceTelephone
h.Document the extentand depth of your experience and qualifications relevant to theProject.
1.Note your specific responsibilities and authorities for each project, not thoseof the firm.
2.Note whether experience iswith current firmorwith other firm.
3.Providebeginningandenddatesforeachproject;projectsolderthanfifteen(15)yearswillnotbe considered for evaluation.
(Listatleastthree(3),butnomorethanfive(5)relevantprojects*forwhichyouhaveperformeda similar function.)
*On-callcontracts withmultiple task orders (on multipleprojects) maynotbe listed as a single project.
i.ForKeyPersonnelrequiredtobeonsitefulltime,provideacurrentlistofassignments,role,andthe anticipated duration of eachassignment.
FORMN
KEY PERSONNELCOMMITMENTFORM
Letterhead
Date
Offeror Name:
Onbehalfof[firmname],asthecurrentemployer of[Key Personnel name],aKey Personnel specifically representedandidentifiedintheI-64HamptonRoadsBridge-TunnelExpansion ProjectStatementofQualifications,Iherebyattestthattheyare/willbemadeavailableupon awardofsaidProject. TheKeyPersonnelwillbecommitted tothisProjectonafull-timebasis forperiodsnecessarytosatisfactorilyfulfilltheirprogrammaticresponsibilities.
Signed:
Printed Name:
Title:
Date:
FORMO
JOINTVENTURE BIDDINGAGREEMENT JointVentureBiddingAgreement
andthefollowingjoint Venturers:
and
ThisJointVentureBiddingAgreementis enteredintobetween:
Locatedat
and
Locatedat
and
Locatedat
and
On this of , 20astheJointVentureName:The purposeofthisJointVentureistobidon uponasolicitation/Contractissuedby The
Virginia Department ofTransportationandifsuccessfullyawarded toprovideservices aslisted underthecontract.
,theManagingVenturer,willsubmitallrequiredbiddocuments and actaspointofcontacton behalfofthisJointVentureduringthebiddingprocess.
Venturer:Vendor#:
Address:DUNS#
Authorized Signature:Date:
PrintedNameof AuthorizedOfficer:(First,Middle,Lastnamesspelledout) Title: Driver’s License#/State Issued: TaxID: PercentageofJointVenture
Lead ContactPhone# LeadFax# Email:
Joint Venturer: Vendor#:
Address: DUNS#
Authorized Signature:Date:
PrintedNameof AuthorizedOfficer:(First,Middle,Lastnamesspelledout) Title: Driver’s License#/State Issued: ReferencePhone# ReferenceFax# PercentageofJointVenture
Joint Venturer:Vendor#:
Address:DUNS#
Authorized Signature:Date:
PrintedNameof AuthorizedOfficer:(First,Middle,Lastnamesspelledout) Title: Driver’s License#/State Issued: ReferencePhone# ReferenceFax# PercentageofJointVenture
Stateof Countyof
On this
day of _
20, before me, the undersigned officer,
personallyappeared known and proven to me to be the person(s) whose name(s) are
subscribedtowithintheinstrumentandacknowledgedthattheyexecutedthesameforthe purposesthereincontained.
Signature VenturerFirm
InwitnesswhereofIhereuntosetmyhandandofficialseal.
NotaryPublic[NotarySeal]
PrintedName Mycommission expires
Revision 06/10/2016
FORMP
OFFERORQUESTIONNAIREFORM
NameofOfferor:
Date:
No. / Topic / RFQSection / Question1.
2.
3.
4.
5.