COMPANY NAME:

STATEMENT OF QUALIFICATION FOR SINGLE PLY ROOFING PROJECTS

Company contact information:

Address 1: / Individual
Address 2: / Partnership
Owner Name: / Corporation
Email: / Joint Venture
Phone: / LLC/LLP or LP
FAX: / Registered in which state?

Application prepared by: Preparer’s email:

Contact for questions: Email for notifications:

Website:

Certification Statement:

The individual whose name is typed and signed on this page, guarantees the truth and accuracy of all answers, statements, and any additional information submitted to process this application. This statement should show the name of the applicant, if a sole proprietor. If a partnership, the application should show the name of an authorized partner. If a corporation, the application should show the name of an authorized officer. If a limited liability company, the application should show the name of an authorized member.

I certify that the foregoing statements and information provided in all sections of this application and any attachments are correct and true as of the date of this application, and that I am authorized to bind this company contractually. I further certify that any additional information requested by the McMinnville School District to process this application will be true and correct. Contractor applicant agrees that if awarded a contract with the McMinnville School District, contractor will comply with all applicable federal, state and local laws, ordinances, and regulations. Contractor will comply with prevailing wage laws for all public improvement projects.

Signature of Individual Authorized to Execute Bids and Contracts Date


Section 1 - ORGANIZATION Information

Fill out appropriate sections.

Sole Proprietorship

If doing business as a sole proprietorship answer this:
Individual’s name liable for all obligations of business
Registration date
Registration number

Assumed Business Name

If doing business under an assumed business name answer this:
Assumed business name
Owner’s name & address

General Partnership

If a general partnership answer this:
Date of organization
If a foreign (out of state) co-partnership or persons engaging in business in the state under an assumed business name, but not domiciled within this state, state whether or not such partnership has been registered as may be required in compliance with Chapter 648, Oregon Revised Statutes.
Yes / Registration No: / Date Registered:
No

Oregon Corporation

If an Oregon corporation answer this:
When incorporated
Registry Number
President
1st Vice President
Secretary
Treasurer
Printed names and titles of officers authorized to execute contracts:


Section 1 - continued

Limited Liability

If a limited liability company, limited liability partnership, or limited partnership indicate which:
Limited Liability Company
Limited Liability Partnership
Limited Partnership
Date organized / Registration number
List members or partners who are authorized to execute contracts
Name and address of registered office and registered agent
OWNERSHIP AND CONTROL

A. List any individuals, companies or corporations owning 10% or more of the applicant's company.

Not applicable

B. List any other company owned or controlled by the applicant, its officers, directors or partners or in which the applicant was or is an officer, director or partner.

Not applicable

C. List all other personnel in applicant's company who have a financial interest in or serve as officers or partners in another company prequalified to bid in the State of Oregon or another State.

Not applicable

Individual's Name / Present Position or Office / Other Company / Position in Other Company / State of Other Company


Section 2 – LICENSING AND CERTIFICATIONS

D. Oregon Construction Contractors Board (CCB):

E. List jurisdictions and trade categories in which your organization is legally qualified to do business and indicate registration or license numbers if applicable:

F. List the categories of work that your organization normally performs with its own employees:

Section 3 – BONDING & Insurance

Bid, Payment and Performance bonding is required for all construction bids with an estimated value of $100,000 or greater.

Indicate your company’s per project and aggregate bonding capacity.

Bonding Per Project $

Aggregate Capacity $

Bonding Requirement: Attach a letter to your application from your Surety Company indicating your bonding limits for Bid, Payment and Performance bonding. The District will not grant bidding limits greater than the “per project” bonding amount stated in the letter from your Surety company. Review of application will be delayed if bonding letter is not included.

Insurance Requirement: Participating Contractor’s will be required to provide certification of insurance at the levels required per the PreQualification Criteria included in the RFQ packet. Attach evidence of insurance currently in place or a letter from your insurance agent stating that the required coverage will be provided within ten days of contract award.

Section 4 - BANKS, EQUIPMENT SUPPLIERS and MATERIAL SUPPLIERS

Provide names and addresses of the BANKS, EQUIPMENT SUPPLIERS and MATERIAL SUPPLIERS with whom you have done the major volume of business in the last three years. (Do not include bank account numbers)

Name of Bank or Company / Address / Name and Phone No. of Officers With Whom
You Transacted Business

Section 5 – EXPERIENCE OF PERSONNEL

List the experience of employees involved in the supervision and application of single ply roofing systems.

Individual's Name / Present Position
or Office / Years working for this company / Years of Roofing
Experience / Roofing systems

Section 6 – Project History

Provide a list of projects – Required Attachment. See Project History Form Provided

A.  Provide a description of similar roofing projects in chronological order that the Participating Contractor has completed in the last five years, with at least three projects completed within the last 24 months. Provide the following details for each project:

1.  Contract type (subcontract or general)

2.  Type of roofing (Include only single ply roofing projects)

3.  Manufacturer

4.  Warranty provided

5.  Client name and address

6.  Total square footage

7.  Construction budget

8.  Number of change orders

9.  Dollar amount of change orders

10.  Number of claims

11.  Number of total requests for information

12.  Date of substantial completion

13.  Date of final closeout

14.  Warranty action

15.  Project contact name and phone number

B.  Provide a similar list of all past work/projects (regardless of type of project) performed specifically for the McMinnville School District.

  1. Provide written certification from manufacturer certifying that installer has been approved by manufacturer for installation of that particular roofing system. (Refer to District adopted roofing standard Appendix A)

Section 7 - Performance and Integrity
Please attach written explanations as appropriate.
A. How many years has your company been in business as a prime contractor under your present business name?
B. Has your company changed its name during the past 10 years? Yes No
If yes, provide your company’s former name:
C. How many years' experience as a roofing contractor has your company had as a:
Prime contractor? Sub-contractor?

D. Has your company ever been denied prequalification by any state, local or federal agency in this or any other state? Yes No If yes, please attach an explanation.
E. Has your company ever failed to complete a state, local or federal public improvement contract? Yes No If yes, please attach an explanation.
F. Has your company had any claims placed against one of your payment bonds or performance bonds in the past 10 years? Yes No If yes, please attach an explanation.
G. Have you or your company ever been debarred from bidding on contracts by any state, local or federal agency in this or any other state?
Yes No If yes, please attach an explanation.
H. Has your company filed for bankruptcy in the past 10 years?
Yes No If yes, please attach an explanation.
I. Has your company had any OSHA violations in the past 10 years?
Yes No If yes, please attach an explanation.
K. Has any officer or partner of your company ever been an officer or partner of another company that failed to complete work under a contract?
Yes No If yes, please attach an explanation.
L. Has any officer or partner of your company ever been failed to complete work under a contract issued under that individual’s own name?
Yes No If yes, please attach an explanation.
M. Within the last three years have you, your company or any officers, agents or employees of your company been found to have violated any State or Federal prevailing wage statute, regulation (including the federal Davis-Bacon and Related Acts and ORS 279C.830 et. seq.) in any Final Order of the Oregon Bureau of Labor and Industries or the US Department of Labor, or by any court of competent jurisdiction?
Yes No
If yes, provide copies of the final order or judgment and explain in detail the following:
§  the circumstances behind any violation, including the amount not paid
§  whether the amounts have now been paid
§  the reasons for the violation
§  all efforts undertaken to ensure that future violations will not occur

END OF STATEMENT OF QUALIFICATION

Statement of Qualification – Single Ply Roofing Systems Page 5