SNA BRUSH MOWING

BID NO. 2016-056-01

QUALIFICATION FORM

VERSION: Original

This Prime Contractor Response Qualification Form must be submitted with your solicitation response. A solicitation response received without this form, or with an outdated version, will be rejected.Prime contractors are responsible for checking all addenda for the final version of this form.

Each responder must answer every question and provide all information requested on this form. Failure to meet this requirement may result in the rejection of the entire solicitation response as non-responsive.

The State (or its representative) reserves the right to verify/clarify the required qualification information submitted on this form before an award is made. The solicitation response will be rejected if qualifications are not met.

Qualification Requirements

1. Responder has been in business under current business name or current Federal Employer ID Number for a minimum of two (2) years from the solicitation response due date.(Responder must check YES or NO)

☐YES / If company name changed within the last two years from soliciation response due date, but Federal Employer ID remains the same, then list Previous Company Name:______
☐NO / Responding “NO” acknowledges that the entire solicitation response will be rejected for not meeting the minimum two years condition stated in Qualification Requirement #1.

2. Responder has substantially completed, as a prime contractor or a subcontractor, the work for at least one written and verifiable contract since January 2011 for conducting woody vegetation mulching or mowing utilizing tracked skid steers equipped with rotary or mulching mower power heads or very similar scope of work

Fill in the required information for your previous projects relating to Qualification Requirement #2:

*Property Owner:
Property Owner Contact Person: / Contact Person’s Telephone #:
Dollar Amount of Contract: / Substantial Completion Date:
Contract substantially completed under (check one): / ☐Current Company Name
☐Previous Company Name
*Property Owner:
Property Owner Contact Person: / Contact Person’s Telephone #:
Dollar Amount of Contract: / Substantial Completion Date:
Contract substantially completed under (check one): / ☐Current Company Name
☐Previous Company Name
*Property Owner:
Property Owner Contact Person: / Contact Person’s Telephone #:
Dollar Amount of Contract: / Substantial Completion Date:
Contract substantially completed under (check one): / ☐Current Company Name
☐Previous Company Name

*The term “Property Owner” means the person or entity identified as the owner of the propertywhere the work referenced for Qualification Requirement #2 was performed.

The State (or its representative) reserves the right to contact the references listed above for Qualification Requirement #2. The solicitation response will be rejected if the State, in its sole discretion, receives information that indicates the responder is non-responsible. Information considered includes, but is not limited to: 1) project milestones (meeting substantial and final completion dates); 2) communication with project owner and subcontractors; 3) on-site supervision; 4) coordination of subcontractors; 5) violation of Minnesota prevailing wage law; and 6) nonpayment of subcontractors.

3. Responder confirms each individual that will be responsible for this solicitation project has had at least 150 hours of experience with woody vegetation removal/mowingsimilar in scope and value to this project.

List below the required information for individuals who will be responsible for this project:

Name______Present Position ______

Operator
Hours / Type of Work / In What Capacity

Name______Present Position ______

Operator
Hours / Type of Work / In What Capacity
4. Has your Company been found in default or had a contract terminated for cause in the last 36 months? / ☐YES
☐ NO
5 Has your Company received from OSHA any willful or repeated safety citations for which a final order has been issued within the last 36 months? / ☐YES
☐ NO
6. Has your company passed the substantial and/or final completion deadlines on a project within the past 36 months for which the owner has or will be charging your company liquidated damages? / ☐YES
☐ NO

Certification

By signing this form, I confirm the information provided is complete and accurate.

Authorized Signature:Date:

Printed Name:Telephone:

Company Name: Title: