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STATE OF HAWAII
STANDARD
QUALIFICATION QUESTIONNAIRE
FOR
OFFERORS
issued by the
PROCUREMENT POLICY BOARD
STATE OF HAWAII
June 16, 2003
To be filed with the procurement officer calling for offers
in accordance with Section 103D-310, HRS, as amended.
Submitted By
Address
Date
STANDARD QUALIFICATION QUESTIONNAIRE
COVERING EXPERIENCE, EQUIPMENT AND FINANCIAL STATEMENT OF OFFERORS. THE OFFICER
CALLING FOR OFFERS MAY REQUIRE THE OFFEROR TO FURNISH ADDITIONAL INFORMATION
NOT SPECIFICALLY COVERED HEREIN. ALL ITEMS MUST BE ANSWERED AND OMISSIONS MAY BE
CONSIDERED GOOD CAUSE FOR UNFAVORABLE CONSIDERATION.
SPO Form-21
GENERAL INFORMATION
1.The statements contained in this Questionnaire are being furnished for consideration in submitting an offer for
the following project:
(a)Project Title
(b)Location
(c)Bid Opening Date
2.The Questionnaire is being submitted in behalf of:
(a)Name of Offeror
License No.
A Corporation
A Partnership
An Individual
A Joint-Venture
Limited Liability
Company
(b)Address
(c)Telephone No.
(d)Date Submitted
3.If the bid is submitted by a joint venture, composed of two or more individual firms, then each member firm
comprising the joint venture must submit all information listed on pages 3 through 16, inclusive, of the
Questionnaire and, in addition, answer the following:
(a)Members of joint Venture
(b)Date of Joint Venture Agreement
(c)Is agreement between members comprising the joint venture joint and several liability?
If not, state the terms of agreement in this respect:
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EXPERIENCE QUESTIONNAIRE
Submitted by
Principal Office
A Corporation
A Partnership
An Individual
A Joint Venture
Limited Liability
Company
The signatory of this questionnaire guarantees the truth and accuracy of all statements and of all answers tointerrogatories hereinafter made
1. How many years has your organization been in business as a [General Contractor] under your present business
name?
2. How many years experience in [construction] has your organization had: (A) as a [General
Contractor ] ; (B) as a [Sub-Contractor]
3. Show what [construction] projects your organization has completed in the past five (5) years in the following
tabulation:
Contract Amt. Class of Work When Completed Name and Address of Owner
3
4. Have you ever failed to complete any work awarded to you? If so, state when, where and
why?
5. Has any officer or partner of your organization in the past five (5) years been an officer or partner of some other
organization that failed to complete a contract? If so, state name of individual, other organization and reason
therefore
6. Has any officer or partner of your organization in the past five (5) years failed to complete a contract handled in his
own name? If so, state name of individual, name of Owner and reason therefore.
7. In what other lines of business are you financially interested?
8. For what corporations or individuals in the past five (5) years have you performed work, and to whom do you
refer?
9. For what counties within the State of Hawaii have you performed work and to whom do you refer?
10. For what Bureaus or Departments of the State government have you performed work and to whom do you refer?
11. Have you performed work for the U. S. Government? If so, when and to whom do you refer?
4
12. Have you ever performed any work for any other governmental agencies outside the State of Hawaii?
If so, when and to whom do you refer?
13. What is the [construction] experience of the principal individuals of your organization?
Individual’s Name Present Position
or Office
Years of
Work
Experience
Magnitude and Type of Work In What
Capacity?
5
EQUIPMENT QUESTIONNAIRE
Submitted by
Principal Office
A Corporation
A Partnership
An Individual
A Joint Venture
Limited Liability
Company
The signatory of this questionnaire guarantees the truth and accuracy of all statements and of all answers tointerrogatories hereinafter made
1. In what manner have you inspected this proposed work? Explain in detail.
2. Explain your plan or layout for performing the proposed work.
3. The work, if awarded to you, will have the personal supervision of whom?
4. Do you intend to do the hauling on the proposed work with your own force? If so, give amount
and type of equipment to be used.
5. If you intend to sublet the hauling or perform it through an agent, state amount of sub-contract or agent's
contract, and, if known, the name and address of sub-contractor or agent, amount and type of his equipment and
financial responsibility
6
6. Do you intend to do grading on the proposed work with your own forces? If so, give type of
equipment to be used
7. If you intend to sublet the grading or perform it through an agent, state amount of sub-contract or agent's
contract, and, if known, the name and address of sub-contractor or agent, amount and type of his equipment and
financial responsibility
8. Do you intend to sublet any other portions of the work? If so, state -amount of sub-
contract, and, if known, the name and address of the sub-contractor, amount and type of his equipment and
financial responsibility
9. From which sub-contractors or agents do you expect to require a bond?
10. What equipment do you own that is available for the proposed work?
Quantity Item Description, Size, Capacity, Etc. Condition Years of Service Present Location
7
11. What equipment do you intend to purchase for use on the proposed work, should the contract be awarded to
you?
Quantity Item Description, Size, Capacity, Etc. Approximate Cost
12. How and when will you pay for the equipment to be purchased?
13. Do you propose to rent any equipment for this work? If so, state type, quantity
and reasons for renting
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FINANCIAL STATEMENT
Submitted by
Principal Office
A Corporation
A Partnership
An Individual
A Joint Venture
Limited Liability
Company
The signatory of this questionnaire guarantees the truth and accuracy of all statements and of all answers tointerrogatories hereinafter made
BALANCE SHEET
As of , 20
Assets
Current assets:
Cash and cash equivalents (1) $
Short-term investments (2)
Accounts receivable, net (3)
Inventories (4)
Costs and estimated earnings in excess of billings
on uncompleted contracts (5)
Prepaid expenses and other (6)
Sub-Total Current Assets
Property and equipment:
Land (7)
Buildings (8)
Vehicles, machinery and equipment (9)
Furniture and fixtures (10)
Less accumulated depreciation ( )
Sub-Total Net Property and Equipment
Other assets:
Cash surrender value of life insurance policies (11)
Deposits and other (12)
Sub-Total Other Assets
Total Assets: $
9
BALANCE SHEET (Continued)
Liabilities and Stockholder’s Equity
Current liabilities:
Current portion of long-term debt (1) $
Accounts payable (2)
Billings in excess of costs and estimated earnings
on uncompleted contracts (3)
Accrued liabilities and other (4)
Sub-Total Current Liabilities
Long-term debt, net of current portion (5)
Sub-Total Liabilities & Long-term Debt: $
Stockholder’s equity:
Capital stock (6)
Additional paid-in capital (7)
Retained earnings
Treasury stock (8) ( )
Sub-Total Stockholder’s Equity $
Total Liabilities and Stockholder’s Equity $
10
DETAILS RELATIVE TO ASSETS
(1) Cash and cash equivalents:
Financial Institution Type of Account Amount
$
$
(2) Short-term investments:
Type of Security Cost
$
$
Unrealized
Gains
$
$
Unrealized
Losses
$
$
Estimated
Fair Value
$
$
(3) Accounts receivable (list major debtors):
Completed Contracts
Name Description
Completion
Date
Contract
Amount
$
$
Amount
Receivable
$
$
Other than completed contracts
Name Description Due Date
Amount
Receivable
$
Less allowance for doubtful accounts ( )
$
(4) Inventories
Description Cost
$
$
Market Value
$
$
Lower of Cost
or Market Value
$
$
11
DETAILS RELATIVE TO ASSETS (Continued)
(5) Costs and estimated earnings in excess of billings on uncompleted contracts
Name Description
Completion
Date
Contract
Amount
$
$
Costs and
Estimated
Earnings to Date
$
$
Billings
to Date
$
$
Costs and Estimated
Earnings in
Excess of Billings
$
$
(6) Prepaid expenses and other
Description Amount
$
$
(7) Land
Description Location Amount
$
$
(8) Buildings
Description Location
$
Amount
$
(9) Vehicles, machinery and equipment
Description Amount
$
$
(10) Furniture and fixtures
Description Amount
$
$
12
DETAILS RELATIVE TO ASSETS (Continued)
(11) Cash surrender value of life insurance policies
Key Employee Insurance Company
$
Policy
Amount
$
Paid-Up
Additional
Insurance
$
CSV
Amount
Less loans payable ( )
$ $ $
(12) Deposits and other
Description Amount
$
$
13
DETAILS RELATIVE TO LIABILITIES AND STOCKHOLDER’S EQUITY
(1)Current portion of long-term debt (maturing within 12 months)
Lender Description
Security
Pledged Due Date Amount
$
$
(2)Accounts payable (list major creditors)
Name
Past Due
Amount
$
Amount
$
$$
(3)Billings in excess of costs and estimated earnings on uncompleted contracts
Name Description
Completion
Date
Contract
Amount
$
Costs and
Estimated
Earnings to Date
$
Billings
to Date
$
Billings in excess
of costs and
Estimated Earnings
$
$ $ $ $
(4)Accrued liabilities and other
Description Amount
$
$
(5)Long-term debt, net of current portion
Lender Description
Security
Pledged Due Date Amount
$
$
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DETAILS RELATIVE TO LIABILITIES AND STOCKHOLDER’S EQUITY (Continued)
(6) Capital stock
No. of Shares
No. of Shares Issued and
Type of Stock Class Authorized Outstanding Par Value Amount
$ $
$
(7) Additional paid-in capital
Description Amount
$
$
(8) Treasury stock
Type of Stock Class
No. of
Shares
$
Cost
$
15
STATEMENTS OF INCOME AND RETAINED EARNINGS
For the Years Ended , 20 and 20
Contract revenues
Costs of contracts
Gross income from contracts
General and administrative expenses
Income from operations
Other income (expense)
Income before income taxes
Income taxes
Net income
Retained earnings, beginning of the year
Retained earnings, end of the year
20
$
$
20
$
$
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If a corporation, answer this:
Capital paid in cash, $
When Incorporated
In what State
Date registered in Hawaii
If a partnership, answer this:
Date o f organization
Date registered in Hawaii
State whether partnership is general or limited
President's name
Vice-President's name
Secretary's name
Treasurer's name
Name and address of partners: Age
The undersigned hereby declares: that the foregoing is a true statement of the financial condition of the individual,
partnership or corporation herein first named, as of the date herein first given; that this statement is for the express purpose of
inducing the party to whom it is submitted to award the offeror a contract; and that any depository, vendor or other agency
herein named is hereby authorized to supply such party with any information necessary to verify this statement.
NOTE: A partnership must give firm name and signatures
of all partners. A corporation must give full corporate
name, signature of official, and affix corporate seal.
Affidavit for Individual
STATE OF HAWAII
COUNTY OF
_________________________________________________________________ being duly sworn, deposes and says that the foregoing financial statement, taken from his books, is a true and accurate statement of his financial condition as of the date thereof and that the answers to the foregoing interrogatories are true.
Sworn to before me this (Applicant must also sign here)
day of 20
Notary Public
Affidavit for Partnership
STATE OF HAWAII
COUNTY OF
__________________________________________________________________ being duly sworn, deposes and says that he is a member of the firm of ______________________________________________________________________; and that he is familiarwith the books of the said firm showing its financial condition: that the foregoing financial statement, taken from the books of the said firm, is a true and accurate statement of the financial condition of the said firm as of the date thereof and that the answers to the foregoing interrogatories are true.
Sworn to before me this (Members of firm must also sign here)
day of 20
Notary Public
Affidavit for Corporation
STATE OF HAWAII
COUNTY OF
___________________________________________________________________ being duly sworn, deposes and says that he is ________________________________ of the ___________________________________________________________, the corporationdescribed in and which executed the foregoing statement; that he is familiar with the books of the said corporation showing its financial condition; that the foregoing financial statement, taken from the books of the said corporation, is a true and accurate statement of thefinancial condition of said corporation as of the date thereof and that the answers to the foregoing interrogatories are true.
Sworn to before me this (Officer must also sign here)
day of 20
Notary Public
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Doc. Date: No. of Pages:
Notary Name: Judicial Circuit
Doc. Description: State of Hawai‘i Standard Qualification Questionnaire for
Offerors for County of Hawai‘i, Department of Public Works
Notary Signature Date
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