REQUALIFICATION

Gentlemen:

We are in the process of updating our records for a portion of our bidders list. Please return this completed form at your earliest opportunity to ensure you remain on the list.

Thank you.

Circle the correct response:

  1. Whom at your organization should we contact (Please include a business card)

Name: ______

Phone No. ______

Cell Phone: ______

Pager: ______

E-mail: ______

2. Indicate if you are certified DBE MBE WBE

3. Are you affiliated with AFL/CIO or other union representation YES NO

4. Bonding Company/Limit:

Name and address of bonding company

______

______

______

Limit:

Have not established bonding capability

$100,000

$500,000

Over $1,000,000 (indicate limit) ______

5. Experience

5.1 Claims and Suits. (If the answer to any of the questions below is yes, please attach details.)

5.1.1Has your organization ever failed to complete any work awarded to it? YES NO

5.1.2Are there any judgments, claims, arbitration proceedings or suits pending or outstanding against your organization or its officers? YES NO

5.1.3Has your organization filed any law suits or requested arbitration with regard to construction contracts within the last five years? YES NO

5.1.4How many mechanics liens has your organization filed in the last five years? YES NO

5.2Within the last five years, has any officer or principal of your organization ever been an officer or principal of another organization when it failed to complete a construction contract? (If the answer is yes, please attach details.) YES NO

5.3On a separate sheet, list the major projects your organization has completed in the past five years, giving the name of project, owner, architect, contract amount, date of completion and percentage of the cost of the work performed with your own forces.

3.6.1State average annual amount of construction work performed during the past five years:

5.4Has the firm, or any firm listed in response to questions 1.7 and 1.11 above, defaulted or been terminated on, or had its surety called upon to complete, any contract awarded within the past five years? If so, give date(s), agency(ies)/owner(s), project(s), contract number(s), and describe, including the result: YES NO

5.6For all contracts within the past five years: (a) list and describe any liens or claims filed against the firm and remaining undischarged or unsatisfied for more than 90 days, and (b) list and describe all liquidated damages assessed:

6. Financing

6.1Financial Statement.

6.1.1Attach financial statements for the past two years, preferably audited, including your organization's latest balance sheet and income statement showing the following items:

Current Assets (e.g., cash, joint venture accounts, accounts receivable, notes receivable, accrued income, deposits, materials inventory and prepaid expenses):

Net Fixed Assets:

Other Assets:

Current Liabilities (e.g., accounts payable, notes payable, accrued expenses, provision for income taxes, advances, accrued salaries and accrued payroll taxes):

Other Liabilities (e.g., capital, capital stock, authorized and outstanding shares par values, earned surplus and retained earnings).

6.1.2Name and address of firm preparing attached financial statement, and date thereof:

6.1.3Is the attached financial statement for the identical organization named on page one? YES NO

6.1.4If not, explain the relationship and financial responsibility of the organization whose financial statement is provided (e.g., parent-subsidiary).

6.2Will the organization whose financial statement is attached act as guarantor of the contract for construction? YES NO

7. Other Information

Within the past five years, has the firm, any affiliate, any predecessor company or entity, or any person identified in question number 1 above been the subject of any of the following: (respond to each question and describe in detail the circumstances of each affirmative answer: attach additional pages if necessary)

a.a judgment or conviction for any business-related conduct constituting a crime under state or federal law? no yes

b.a criminal investigation or indictment for any business-related conduct constituting a crime under state or federal law? no yes

c.a grant of immunity for any business-related conduct constituting a crime under state or federal law? no yes

d.a federal or state suspension or debarment? no yes

e.a rejection of any bid for lack of qualifications, responsibility or because of the submission of an informal, non-responsive or incomplete bid? no yes

f.a rejection of any proposed subcontract for lack of qualifications, responsibility or because of the submission of an informal, non-responsive or incomplete bid? no yes

g.a denial or revocation of pre-qualification? no yes

h.a voluntary exclusion from bidding/contracting agreement? no yes

i.any administrative proceeding or civil action seeking specific performance or restitution in connection with any public works contract except any disputed work proceeding? no yes

j.an OSHA Citation and Notification of Penalty containing a violation classified as serious? no yes

k.an OSHA Citation and Notification of Penalty containing a violation classified as willful? no yes

l.a prevailing wage or supplement payment violation? no yes

m.a State Labor Law violation deemed willful? no yes

n.any other federal or state citations, Notices, violation orders, pending administrative hearings or proceedings, or determinations of a violation of any labor law or regulation? no yes

o.any criminal investigation, felony indictment or conviction concerning formation of, or any business association with, an allegedly false or fraudulent women's, minority or disadvantaged business enterprise? no yes

p.any denial, decertification, revocation or forfeiture of Women's Business Enterprise, Minority Business Enterprise or Disadvantaged Business Enterprise status? no yes

q.rejection of a low bid on a State contract for failure to meet statutory affirmative action or M/WBE requirements? no yes

r.a consent order with the NYS Department of Environmental Conservation, or a federal, state or local government enforcement determination involving a violation of federal or state environmental laws? no yes

s.any bankruptcy proceedings? no yes

t.any suspension or revocation of any business or professional license? no yes

u.any citation, Notices, violation orders, pending administrative hearings or proceedings or determination for violations of:

-federal, state or local health laws, rules or regulations no yes

-unemployment insurance or workers compensation coverage or claim requirements no yes

-ERISA (Employee Retirement Income Security Act) no yes

-federal, state or local human rights laws no yes

- federal or state security laws no yes

None of the above

09/27/18