JEFFERSON COUNTY SCHOOL DISTRICT NO. R-1
CONTRACTOR
PRE-QUALIFICATION STATEMENT
1.0 Specify contract(s) requesting to be pre-qualified for:
2.0 Provide Firm Information, local office and principle office if other than local office designated:
Contact Person:
Current Legal Name:
Street Address:
City/State/Zip:
Telephone Number:
Fax Number:
E-mail Address:
2.1 How many years has your firm been in business?
3.0 Please check the appropriate box to identify the nature of your firm.
Corporation Partnership
Other Individual
3.1 Provide an organizational chart for your firm.
3.2 Corporations: provide a copy of the most recent Annual Report
Date firm Incorporated
State where firm is incorporated
County where firm is incorporated
Name of President
Name of Vice President(s)
Name of Secretary
Name of Chief Financial Officer
3.3 Partnership or individual: provide the following information.
Date firm established
Name and address of individual/partners (Indicate partners and whether general or limited partners).
Name Address
3.4 Other types of firms: list the names and addresses of principals.
4.0 What type of work and approximately what percentage of work would be performed by your own forces on this project?
Type Percentage
General
5.0 Has your firm failed to accept a contract award or to complete a contract awarded to you? If your response was "yes" to the previous question please, state the project(s), date, owner and reason.
6.0 Has your firm ever had a contract terminated? If "yes", state the project(s), date, owner and reason.
7.0 Bonding Information:
Name of bonding company
Bests Rating
Bests Financial Rating
Name and address of bonding company agent
Bonding Capacity: Maximum Bonding Value $
Current Value of bonded Projects $
8.0 Has your bonding company ever been required to perform or complete work under a bid bond, labor and material payment bond, or performance bond issued on your firm's behalf? If "yes", state the project(s), date, owner and reason.
9.0 Within the last five years has your current firm or any predecessor organization been involved as a party in any bankruptcy, litigation or arbitration proceedings? If your response to the previous question was "yes", please attach a separate sheet with explanation.
10.0 Within the past two (2) years has your firm or predecessor firm received a Notice of Violation and/or Non-compliance notice from any Local Municipality, State or Federal agency? If your response to the previous question was "yes", please attach a separate sheet with explanation.
11.0 Current Work: On a separate page list the projects your firm has completed in the past five years or currently has in progress stating the name of the owner and telephone number, name of project, brief project description, the name of the architect and telephone number, location of project, original contract amount, current contract amount, percentage of completion, and scheduled completion date.
12.0 Resumes: Provide on separate sheets of paper, resumes/experience for key staff in your firm including project managers, superintendents, estimators, schedulers or others that will work on JeffCo projects. For Project Manager and Superintendent include how long employee has been with your firm and project reference contact information for past five years projects.
13.0 Provide a list of individuals in your company who have received training in Stormwater Management Planning. Attach a copy of the certificate for each individual.
14.0 Does your firm have a company wide safety program?
14.1 Is a copy of the safety program available to JeffCo for examination?
14.2 Attach a sample site specific safety plan.
14.3 Does your firm have a safety officer? If so, attach a resume.
15.0 What is your current experience modification rate (EMR) for Worker's Compensation?
16.0 Does your firm provide a bona fide health benefit retirement plan for your employees?
16.1 What percentage of your current employees is covered by your plan?
16.2 Is a copy of your health benefit and retirement plan available to JeffCo for examination?
17.0 Does your firm have a pre-hire criminal background program?
18.0 Does your firm have a pre-hire drug-testing program?
18.1 Does your firm require that subcontractors working on your project have a pre-hire drug-testing program?
18.2 Does your firm have a policy to insure a drug free work place?
18.3 Is a copy of the procedure to enforce this policy available to JeffCo for examination?
19.0 Does your firm participate in an affirmative action program?
19.1 Is a copy of the Affirmative Action Program available to JeffCo for examination?
20.0 Attach a financial statement, preferably an audited statement, including your firm's latest balance sheet and income statement showing the following items:
§ Current Assets, Net Fixed Assets, Other Assets, Current Liabilities, Other Liabilities
§ Name of firm preparing financial statement and date prepared.
§ Explain any difference between firm for which financial statement was prepared and firm listed in section 2.0 of this statement (e.g., parent, subsidiary, joint venture, etc.)
20.1 Bank References; name and contact information.
20.2 Trade and/ or Vendor References; name and contact information
I hereby certify that the information provided in this statement is true and correct.
By Title
Print Name
Date
State of Colorado
County of
The foregoing statement was acknowledged before me this day of , 20
by as
of
My commission expires
Witness by hand and official seal Notary
Address
200810_Contractor__Prequalification_form
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