HomeMy WebLinkAboutStandard Qualification Questionnaire (SQQO) (2)Submitted By
Address
Date
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.
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 Fonn -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.
(b) Address
(C) Telephone No.
(d) Date Submitted
A Corporation
A Partnership
An Individual
A Joint - Venture
Limited Liability
Company
3. If the bid is submitted by a joint venture, composed of two or more individual (inns, then each member Finn
comprising the joint venture must submit all infonnation 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 tenns of agreement in this respect:
2
EXPERIENCE QUESTIONNAIRE
Submitted by
Principal Office
A Corporation
A Partnership
F 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 to
interrogatories hereinafter made
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]
Contractor ] ; (B) as a [Sub - Contractor]
has your organization had: (A) as a [General
3. Show what [construction] projects your organization has completed in the past five (5) years in the following
tabulation:
Contract Aint. Class of Work When Completed Name and Address of Owner
3
4. Have you ever failed to complete any work awarded to you?
why?
If so, state when, where and
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 perfonned work, and to whom do you
refer?
9. For what counties within the State of Hawaii have you perfonned work and to whom do you refer?
10. For what Bureaus or Departments of the State government have you perfonned work and to whom do you refer?
11. Have you perfonned work for the U. S. Government? If so, when and to whom do you refer?
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?
EQUIPMENT QUESTIONNAIRE
Submitted by
Principal Office
F A Corporation
F 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 to
interrogatories hereinafter made
1. In what manner have you inspected this proposed work? Explain in detail
2. Explain your plan or layout for perfonming 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
rr.
Do you intend to do grading on the proposed work with your own forces?
equipment to be used
If so, give type of
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
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, Condition Years of Present Location
Etc. Service
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?
and reasons for renting
If so, state type, quantity
FINANCIAL STATEMENT
Submitted by
Principal Office
A Corporation
A Partnership
F 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 to
interrogatories hereinafter made
BALANCESHEET
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:
pi
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
11
Unrealized
Unrealized
Estimated
Type of Security Cost
Gains
Losses
Fair Value
(3) Accounts receivable (list major debtors):
Completed Contracts
Completion
Contract
Amount
Name Description
Date
Amount
Receivable
Other than completed contracts
Amount
Name Description
Due Date
Receivable
Less allowance for doubtful accounts
( )
$
(4) Inventories
Lower of Cost
Description
Cost
Market Value
or Market Value
11
DETAILS RELATIVE TO ASSETS (Continued
(5) Costs and estimated earnings in excess of billings on uncompleted contracts
(6)
Name Description
Prepaid expenses and other
Completion
Date
$
$
Description
Costs and
Contract Estimated Billings
Amount Earnings to Date to Date
$ $
$ $
Costs and Estimated
Earnings in
Excess of Billings
$
$
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
Paid -Up
Policy Additional CSV
Key Employee Insurance Company Amount Insurance 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)
Security
Lender Description Pledged Due Date Amount
$
14
$
(2)
Accounts payable (list major creditors)
Past Due
Name
Amount
Amount
(3)
Billings in excess of costs and estimated earnings on uncompleted contracts
Costs and
Billings in excess
Completion
Contract Estimated Billings
of costs and
Name Description Date
Amount Earnings to Date to Date
Estimated Earnings
$
$ $
$
$
$ $
$
(4)
Accrued liabilities and other
Description
Amount
(5)
Long -term debt, net of current portion
Security
Lender Description
Pledged Due Date
Amount
$
$
14
DETAILS RELATIVE TO LIABILITIES AND STOCKHOLDER'S EQUITY (Continued)
(6) Capital stock
No. of Shares
Type of Stock Class Authorized
(7) Additional paid -in capital
(8) Treasury stock
Type of Stock
Description
Class
15
No. of Shares
Issued and
Outstanding
Par Value
No. of
Shares
ii
Amount
Amount
Cost
STATEMENTS OF INCOME AND RETAINED EARNINGS
For the Years Ended
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
16
20 and 20
20 20
If a corporation, answer this:
Capital paid in cash, $
When Incorporated
In what State
Date registered in Hawaii
President's name
Vice - President's name
Secretary's name
Treasurer's name
If a partnership, answer this:
Date o f organization
Date registered in Hawaii
State whether partnership is general or limited
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
day of 20
Notary Public
Affidavit for Partnership
STATE OF HAWAII
COUNTY OF
(Applicant must also sign here)
being duly sworn, deposes and says that he is a
member oI the firm o- and that he is familiar
with the books of the said—f—irm showing its tinanciaT con&rtion: tha�ie foregoing tinanciaT statement, taken 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
day of 20
Notary Public
Affidavit for Corporation
STATE OF HAWAII
COUNTY OF
(Members of firm must also sign here)
being duly sworn, deposes and says that he is
of the , the corporation
described 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 the
financial condition of said corporation as of the date thereof and that the answers to the foregoing interrogatories are true.
Sworn to before me this
day of 20
Notary Public
17
(Officer must also sign here)
Doc. Date:
Notary Name:
No. of Pages:
Judicial Circuit
Doc. Description: State of Hawaii Standard Qualification Questionnaire for
Offerors for County of Hawaii, Department of Public Works
Notary Signature
18
Date