Note: Failure to answer all of the following questions may result in disqualification.  If you have any questions, contact the person listed below under “Submitted to.”  The State agency/institution reserves the unqualified right to reject any or all proposals and to waive informalities.  The State agency/institution has developed a plan to meet or exceed goals set by GS 143-128 for the participation of minority businesses in public construction contracts.  Contractors are expected to be familiar with these initiatives and to comply with program requirements.     
 
Due Date: 		__________ 	____________ 
   			Date   		Time 

Submitted to:  	______________________________________________________ 
   			Contact Name 
______________________________________________________ 
   			Agency/Institution 
______________________________________________________ 
   			Address 
____________________________________  ____      _______
   			City                                             State     Zip Code 

Project Title:  	_______________________________________________________________ 
 
Project Description: 	_______________________________________________________________ 
_______________________________________________________________ 
_______________________________________________________________ 
 
I. Minimum Requirements 
 
 A. Firm’s Name and Principal Office serving this project: 
 
  	Company Name: ______________________________________________ 
               	Address: ______________________________________________ 
  ______________________________________________ 
   City:  _______________________________ State: ____   Zip: ________ 
     
     	 Contact Name:	 ______________________________________________ 
                 Phone: (____) ____ - _______   Extension: _______ 
                 Email:	 ______________________________________________ 
 
 B. Type of Company (check one):  ___ Corporation 	 ___ Individual     ___Partnership 
      ___ Joint Venture ___ Other (please specify):____________________________ 
 
 C. Type of Work (check one; file separately for each classification of work): 
 
   __ General Construction  __ Mechanical  __ Plumbing 
   __ Electrical                 Other (please specify):______________________ 

D.	 License   
 
North Carolina License Type (check):    ___ General Construction ___ Mechanical   
___ Plumbing     ___ Electrical    ___ Other (please specify):_____________ 

  	North Carolina License Number: ________________________________________ 
 
  	License Limitations or Level: ___________________________________________ 
 
  	State/County/City Privilege License: ____________________________________ 
        						 (attach copy) 
 
 E. 	Bonding 

1.	Attach letter, dated within the last 30 days, from your surety company or its agent licensed to do business in North Carolina, verifying your company’s capability and capacity based on your current value of work for providing sufficient performance and payment bonds for this project. Surety company bond rating shall be rated “A” or better under the A.M. Best Rating system or The Federal Treasury List. 

2.	Have any funds been expended by a surety company on your behalf? ___ Yes ___ No 
If yes, explain: __________________________________________________________________________________________________________________________________________ 
 
3.	List all surety companies that have provided bonds for your company for the past five (5) years, 
explanation required if more than one company. 
 
___________________________________________________________ 
 Date    					Firm 
   
___________________________________________________________ 
 Date    					Firm 
  
___________________________________________________________ 
 Date    					Firm 
 
F. 	Insurance 
 
In order to pre-qualify, firms must indicate that they can provide evidence of insurance coverage as follows, should they subsequently be the successful bidder. Evidence of insurance in the required amounts can be provided. 
 
1.  Worker’s Compensation insurance as required by law and Employer’s Liability Insurance coverage with minimum limits of $100,000. 
  
2.  General liability insurance with minimum limits of $500,000 per occurrence for bodily injury and $100,000 per occurrence/$300,000 aggregate for property damage. 

3.  Builder’s risk at the full insurable value of the entire work site. 
  
Can your provide evidence of the above insurance? : ___ Yes ___ No 
 
II. General Requirements 
 
A. Experience 
 
1.	Number of years in business as a contractor under the company name listed in I.A., 
above: _______ years.  List any other names your firm operated under previously. 
     __________________________________________________________________ 
 
2.	List date, State and type of incorporation, partnership, or proprietorship establishment:

___________________________________________________________________ 
      Date   		 State/Type (incorporation, partnership/proprietorship) 

3.	List names of the firm principals appropriate to the type of the firm: 
 
Corporation – 	      President: _________________________________________ 
  	Vice-President: __________________________________________ 
     Secretary:	__________________________________________ 
     Treasurer: __________________________________________ 
 
 Partnership –        Partners: __________________________________________ 
 
 Proprietorship –      Owner: ___________________________________________ 
 
 Other – (List and explain):    ___________________________________________
 
4.	Has your company ever performed construction work for the State of North Carolina and/or related public agencies and/or this specific agency/institution?  ___Yes __ No 
 
   	If yes, on a separate sheet list the name of the agency, project, dollar value, owner and architect names and contact phone numbers, scheduled completion and actual completion dates for all projects completed within the last five (5) years.  
 
5.	Has your organization been pre-qualified to bid on a State agency/institution project and failed to submit a bid?  ___ Yes ___ No 
 
If yes, on a separate sheet list name of project and reason you did not submit a bid. 

 
B. 	Size/Capacity  
  
  	1.  How many full-time permanent employees work for the company? : _____________ 
 
2.  If the company has more than one office location, how many full-time permanent 
     employees work for the company at the location which will serve this project? _____ 
 
4.	List the annual dollar value of construction work the company has performed for each 
year over the last 5 calendar years:  
(1)___________  (2) __________ (3) __________ (4) __________ (5) __________ 
                                                              
C.  	 Office Locations 
 
1.	If your company has multiple office locations, indicate the location of the principal place of business: 
________________________________________ 
                      (City/State/Country) 
 
2.   If your company has multiple office locations, indicate the location that will service this project: _________________________________ 
                (City/State/Country) 
 
3.   How many full-time permanent positions from your company will be located in North Carolina, and have payroll taxes paid in North Carolina? : ________________ 
                                                       		(# of positions) 
 
D. 	Workload 
 
1.   How many projects do you currently have under contract or in progress and what is their total dollar value? :   _____________  projects totaling  $________________ 
          (# of projects)                                                   (total $ value)          
 
2.   List the three biggest contracts currently under contract or in progress, including the name of the project, owner and architect names and phone numbers, contract dollar values, percentage complete and currently anticipated completion dates. (attach additional sheets if needed) 
  
(1)     Project:___________________________________________________________ 
          Owner: ____________________________________ Phone: (___) ___ - _______ 
      Architect: ____________________________________ Phone: (___) ___ - _______ 
    $ Contract: _____________   % Complete _____   Completion Date: _____________ 
 
(2)     Project: ___________________________________________________________ 
          Owner: ____________________________________ Phone: (___) ___ - _______ 
      Architect: ____________________________________ Phone: (___) ___ - _______ 
    $ Contract: _____________   % Complete _____   Completion Date: _____________ 

(3)     Project: ___________________________________________________________ 
          Owner: ____________________________________ Phone: (___) ___ - _______ 
      Architect: ____________________________________ Phone: (___) ___ - _______ 
     $Contract: _____________   % Complete _____   Completion Date: _____________ 
 
E. 	Quality Control/Administration 
 
1.   Describe quality control procedures, including contractor inspection and approval processes, to be applied to this project.  List the most recent project where these procedures were used, and provide owner and architect contact names and telephone numbers. (attach additional sheet if needed) 
      __________________________________________________________________ 
      __________________________________________________________________ 
      __________________________________________________________________ 
      __________________________________________________________________ 
      __________________________________________________________________ 
 
2.   Describe management plans for processing Requests for Information (RFI’s), shop drawings, submittals, value engineering, change orders, proposals, and requests for deviations.  Identify key personnel assigned to these or other special issues.  Describe your approach to dispute and claims resolution. (attach additional sheets if needed) 
      __________________________________________________________________ 
      __________________________________________________________________ 
      __________________________________________________________________ 
      __________________________________________________________________ 
      __________________________________________________________________ 
 
F. 	Financials 

Attach latest balance sheet and income statement if available, based on company type.  Audited statements preferred.  If not available, attach a copy of the latest annual renewal submission to the relevant licensing board.  (Firm must submit financial data and may clearly indicate a request for confidentiality to avoid this item becoming part of a public record.)  Indicate Dunn & Bradstreet (www.dnb.com) rating if one exists: _______________ 
  									Rating 
 
List any lines of credit, including the identification of the financial institution holding the credit line, contact name and phone number at the institution, current total line of credit, current balance available, and effective date of the stated balances (must be within the last 30 days). (attach additional sheets if needed) 
____________________________________________________________________ 
____________________________________________________________________ 
____________________________________________________________________ 
  
Note: As provided by statute, the [name of agency/institution] will consider keeping trade secrets which the bidder does not wish disclosed confidential.  Each page shall be identified in boldface at the top and bottom as “CONFIDENTIAL” by the bidder.  Cost information shall not be deemed confidential.  In spite of what is labeled as a trade secret, the determination whether it is or not will be determined by North Carolina law. 

G.	Litigation/Claims.   
 
If yes, attach a separate sheet listing the project(s), dollar value,contact information for  
owner and architect, date of completion, explain the nature of the claim/delay (item 2), and attach relevant documentation.  
 
1.	Has your company ever failed to complete work awarded to it?    ___ Yes  ___ No 

2.	Has your company ever failed to substantially complete a project in a timely manner 
(i.e. more than 20% beyond the originally contracted, scheduled completion date)?   
___ Yes  ___ No   

3.	Has your company filed any claims with the North Carolina Office of State Construction within the last five years? ___ Yes  ___ No 

4.	Has your company been involved in any suits or arbitration proceedings within the
last five years?  ___ Yes  ___ No 

5.	Are there currently any judgments, claims, arbitration proceedings or suits pending or outstanding against your company, its officers, owners, or agents?  ___ Yes  ___ No 

6.	Has your present company, its officers, owners, or agents ever been convicted of charges relating to conflicts of interest, bribery, or bid-rigging?       ___ Yes  ___ No 

7.	Has your present company, its officers, owners, or agents ever been barred from
bidding public work in North Carolina?   ___ Yes  ___ No     

If yes, explain: ________________________________________________________ 

 
H.	Safety Record for the past three years: 
 
1.	List your company’s Experience Modification Rate (EMR) _____________________ 
                                                                                                     rate 
 
2.	List your company’s Incidence Recordable Rate (IRR)        _____________________            
rate 
 
3.	List your company’s Lost Day Case Rate (LDCR)               _____________________ 
                                                                                                    rate 
 
4.	If these rates reflect corporate performance over a number of locations, please explain, to the extent possible, the performance experience of the location serving this project. (attach additional sheets if needed) 
__________________________________________________________________ 
__________________________________________________________________ 
__________________________________________________________________ 
__________________________________________________________________ 

I. 	HUB Plan  
 
1.	Does the company currently have a documented plan for engaging subcontractor
participation from Historically Underutilized Businesses?    ___ Yes   ___ No   

2.	What has been your company’s typical percentage level of Historically Underutilized Business participation for similar projects in this locale?  _____% 
 
 List an example project including name, percentage achieved and owner representative’s
 name and telephone number. (attach additional sheets if needed) 
  	__________________________________________________________________ 
      	__________________________________________________________________ 
      __________________________________________________________________ 
      __________________________________________________________________ 
      __________________________________________________________________ 
      __________________________________________________________________ 

III. Project-Specific Requirements 
 
A.	Project-Specific References – [General project references were requested in section II. A. 4., based on a “Yes” response, and II. D. 2.]  Please identify at least three (3) projects most closely reflecting the size and complexity of the type of work being requested for the currently proposed project.   The similar projects should be completed within the last ten (10) years and at least one of which within the last five (5) years.  If this information is already reflected in responses to earlier sections, please simply identify the relevant projects and detailed information. (attach additional sheets if needed) 

(1) Project Name:_____________________________________________________________ 
      $ Original Contract: ___________________  $ Final Contract:______________________ 
Scheduled Completion: ___/ ___ / ___         	Actual Completion: ___/ ___/ ___ 
Narrative: (describe the project and its similarity to the proposed project) 
 _________________________________________________________________________ 
 _________________________________________________________________________ 
 _________________________________________________________________________ 
 _________________________________________________________________________ 
 _________________________________________________________________________ 
 _________________________________________________________________________ 
 
 Performance on this project: __________________________________________________ 
 Performance rating or letter of commendation (attached) from the owner: ______________ 
 Owner Contact Name: _________________________________ Phone: (___) ___ - ______ 
 Architect Contact Name: _______________________________ Phone: (___) ___ - ______ 

  
(2) Project Name:_____________________________________________________________ 
      $ Original Contract: ___________________  $ Final Contract:______________________ 
Scheduled Completion: ___/ ___ / ___         	Actual Completion: ___/ ___/ ___ 
Narrative: (describe the project and its similarity to the proposed project) 
      _________________________________________________________________________ 
      _________________________________________________________________________ 
      _________________________________________________________________________ 
      _________________________________________________________________________ 
      _________________________________________________________________________ 
      _________________________________________________________________________ 
 
 Performance on this project: __________________________________________________ 
 Performance rating or letter of commendation (attached) from the owner: ______________ 
 Owner Contact Name: _________________________________ Phone: (___) ___ - ______ 
 Architect Contact Name: _______________________________ Phone: (___) ___ - ______ 

 (3) Project Name:____________________________________________________________ 
      $ Original Contract: ___________________  $ Final Contract:______________________ 
Scheduled Completion: ___/ ___ / ___         	Actual Completion: ___/ ___/ ___ 
      Narrative: (describe the project and its similarity to the proposed project) 
      _________________________________________________________________________ 
      _________________________________________________________________________ 
      _________________________________________________________________________ 
      _________________________________________________________________________ 
      _________________________________________________________________________ 
      _________________________________________________________________________ 
 
 Performance on this project: __________________________________________________ 
 Performance rating or letter of commendation (attached) from the owner: ______________ 
 Owner Contact Name: _________________________________ Phone: (___) ___ - ______ 
 Architect Contact Name: _______________________________ Phone: (___) ___ - ______ 

B.	Staffing and Organizational Structure 
 
1.  Provide organizational structure reflecting authority, responsibility and proportion of time dedicated to this project for all key personnel and job descriptions. As attachments, include qualifications (resumes) of the project team key personnel to be assigned to this project.  For each resume, include name, length of time employed with your company, proposed position, education and training, professional registrations/ licenses, and affiliations, company and project-specific employment history.  
 
2.   Project-specific Staff Experience - Project-specific employment history is requested for key personnel for similar projects performed within the last five years.  Information should include project size and description, time and budget performance, position held, authority and responsibilities, contributions made to project success, and include owner/architect contacts with phone numbers.  Provide evidence that the key personnel have worked together successfully as a team.  
 
3.   Staff Availability - Are key personnel also proposed on any other projects for which bidding and contracting is pending?   ___ Yes  ___ No    
 
 If yes, describe general availability and qualifications of potential substitutes.  

C.    [This section reflects any further project-specific or unique project requirements, such as clean room, hospital/medical, prison, LEED certification, construction recycling, schedule constraints, etc. DO NOT REPEAT ABOVE QUESTIONS.] 
      _________________________________________________________________________ 
      _________________________________________________________________________ 
      _________________________________________________________________________ 
      _________________________________________________________________________      _________________________________________________________________________      _________________________________________________________________________ 

IV. Signatures

 By signing this document, you are acknowledging that all answers are true to the best of your knowledge.

A.	Dated this day of: _______________________ 
 
Submitted by:   __________________________________ 
Name of Contractor’s Contact 
			__________________________________ 
       		 Company Name (as licensed in NC) 
        	______________________________________________________________ 
        	Address     
	_________________________________________  ______  _____________ 
      City                         State              Zip Code 

	Phone:        	(___) ____ - _________ 
                	Contact person’s phone number 
 
E-mail:    	_________________________________________ 
                	Contact person’s e-mail address 
 
Signature: 	 ____________________________________ 
   		By Authorized Officer 
 
  		_____________________________________ 
   		Title of Authorized officer (typed) 

B.	NOTARY CERTIFICATION 

North Carolina 
 _________________County 
 
I, a Notary Public of the County and State aforesaid, certify that ________________________, personally appeared before me this day and acknowledged the execution of the foregoing instrument.  Witness my hand and official seal, this the  ________________ day of                        , 20    . 

Official Seal or Stamp         

								
								Notary Public 

 
My commission expires _________________________, 20____.