Passhe Form 150 Asp – Fill Out and Use This PDF

STATE SYSTEM OF HIGHER EDUCATION

COMMONWEALTH OF PENNSYLVANIA

APPLICATION FOR SPECIFIC PROJECT

PASSHE FORM 150 ASP

(This form is a modified version of DGS Form 150 – ASP, by and for the use of the State System of Higher Education)

IF SUBMITTED BY SINGLE FIRM

PRIME FIRM NAME

ADDRESS OF OFFICE TO PERFORM WORK

2.PARENT COMPANY NAME

(If None, State “None”)

ADDRESS

FEDERAL EMPLOYEE IDENTIFICATION NUMBER

5. LEGAL STRUCTURE OF FIRM

6. PERSONNEL BY DISCIPLINE

List the number of personnel by discipline that are presently regular employees of the Prime Firm at the office location designated to perform the work. Each person should be counted only once in accord with his/her primary function.

7.JOINT VENTURE FIRMS AND RESPONSIBILITIES

For a Joint Venture, list participating firms and briefly outline specific areas of responsibility for each firm. If the Joint Venture receives a contract, a copy of the Joint Venture Agreement must be provided. Complete Items 1 through 6 of this form for each Joint Venture firm.

8.SUBCONTRACTED FIRMS

Designate the firms that will hold subcontracts with the Prime Firm for this project. Firms must be utilized by the Prime Firm and may be changed only upon approval of the System.

9. KEY PERSONNEL in PRIME/JOINT VENTURE

Complete for the key personnel of the Prime Firm/Joint Venture Firms to be assigned to this project. Use additional pages as needed. One or two-page résumés may be provided at the end of this document.

10. KEY PERSONNEL in SUBCONTRACTED FIRMS

Complete for the key personnel of Subcontracted Firms to be assigned to this project. Use additional pages as needed. One or two-page résumés may be provided at the end of this document.

11.RELEVANT EXPERIENCE (5 Projects)

Describe 5 projects performed by the Prime Firm/Joint Venture Firms that best illustrate current qualifications relevant to this project. Projects should have been performed by the office location designated to perform the work. Do not list projects performed by Subcontracted Firms, but if a Subcontracted Firm also worked on a listed project, it may be noted. Relevant projects performed by key personnel during previous employment may also be listed.

PROJECT NO. 1

PROJECT NAME

PROJECT LOCATION

PROJECT DESCRIPTION

NATURE OF FIRM’S RESPONSIBILITY (If work was done by Subcontracted Firms listed in Block 8, and/or key personnel listed in Blocks 9 and 10, identify them and their responsibilities on this project.)

SCHEDULE DATES (indicate whether actual or projected)

OWNER and CONTACT PERSON (Name, Address, Phone, E-mail) May be contacted as a reference.

COMMENTS/WHAT MAKES THIS PROJECT RELEVANT?

PROJECT NO. 2

PROJECT NAME

PROJECT LOCATION

PROJECT DESCRIPTION

NATURE OF FIRM’S RESPONSIBILITY (If work was done by Subcontracted Firms listed in Block 8, and/or key personnel listed in Blocks 9 and 10, identify them and their responsibilities on this project.)

SCHEDULE DATES (indicate whether actual or projected)

OWNER and CONTACT PERSON (Name, Address, Phone, E-mail) May be contacted as a reference.

COMMENTS/WHAT MAKES THIS PROJECT RELEVANT?

PROJECT NO. 3

PROJECT NAME

PROJECT LOCATION

PROJECT DESCRIPTION

NATURE OF FIRM’S RESPONSIBILITY (If work was done by Subcontracted Firms listed in Block 8, and/or key personnel listed in Blocks 9 and 10, identify them and their responsibilities on this project.)

SCHEDULE DATES (indicate whether actual or projected)

OWNER and CONTACT PERSON (Name, Address, Phone, E-mail) May be contacted as a reference.

COMMENTS/WHAT MAKES THIS PROJECT RELEVANT?

PROJECT NO. 4

PROJECT NAME

PROJECT LOCATION

PROJECT DESCRIPTION

NATURE OF FIRM’S RESPONSIBILITY (If work was done by Subcontracted Firms listed in Block 8, and/or key personnel listed in Blocks 9 and 10, identify them and their responsibilities on this project.)

SCHEDULE DATES (indicate whether actual or projected)

OWNER and CONTACT PERSON (Name, Address, Phone, E-mail) May be contacted as a reference.

COMMENTS/WHAT MAKES THIS PROJECT RELEVANT?

PROJECT NO. 5

PROJECT NAME

PROJECT LOCATION

PROJECT DESCRIPTION

NATURE OF FIRM’S RESPONSIBILITY (If work was done by Subcontracted Firms listed in Block 8, and/or key personnel listed in Blocks 9 and 10, identify them and their responsibilities on this project.)

SCHEDULE DATES (indicate whether actual or projected)

OWNER and CONTACT PERSON (Name, Address, Phone, E-mail) May be contacted as a reference.

COMMENTS/WHAT MAKES THIS PROJECT RELEVANT?

12.ADDITIONAL INFORMATION

Provide any additional information or description of resources supporting the qualifications of the Prime Firm/Joint Venture Firms and the Subcontracted Firms. If the Prime Firm/Joint Venture Firms have offices in addition to the office location designated to perform the work, provide information on those other offices and personnel, particularly if they represent a resource that might assist in performance of the work. Use additional pages as needed.

13. RELATED WORK - CURRENT AND PREVIOUS WORK OF PRIME FIRM/JOINT VENTURE FIRMS AND SUBCONTRACTED FIRMS

∙List all DGS and PASSHE projects and/or contracts for which the Prime Firm, Joint Venture Firms, and all Subcontracted Firms have been designated as Professional-of-Record, retained as a consultant, or similar function. Indicate that role with the Project/Contract No.

∙Include all projects and/or contracts for which a certificate of completion was executed within the last five (5) years, for which a certificate of completion has not been executed, and for which the firm was selected but not yet under contract.

Use additional pages as needed.

OUTCOME OF FILING

15.LEGAL SANCTIONS

Have any of the Prime Firm/Joint Venture Firms of the Subcontracted Firms, any of their individual members, any officer, or any principal been the subject of any professional or legal sanctions against them in connection with their work?

16.SIGNATURE

The Signatory below certifies that the information contained in this Form 150-ASP is true. False statements made in this document are punishable under 18 P.S. 4904.

By signing this application, the Applicant consents to the evaluation of its performance by the State System of Higher Education and understands that any such evaluation may be used in future selections of firms. The Applicant’s Subcontracted Firms may also be evaluated.

The Applicant is required to notify each of its Subcontracted Firms that, in contracting with the Applicant, the Subcontracted Firms consent to the System’s evaluation of the Subcontracted Firms and to the use of any such evaluation in future selections of firms.