Tdot Prequalification Questionnaire Form – Fill Out and Use This PDF

STATE OF TENNESSEE

DEPARTMENT OF TRANSPORTATION

Nashville, Tennessee

PREQUALIFICATION

QUESTIONNAIRE

(Begin Date Last Fiscal Year)

(End Date Last Fiscal Year)

By

Legal Business Name under which you wish to Qualify

Street Address

City and State

Zip Code

Telephone Number

Fax Number

E-Mail Address

Submitted as required by the State of Tennessee, Department of Transportation, under the provisions of Section 54-5-117, Tennessee Code Annotated, and Tennessee Department of

Transportation Rule 1680-5-3, Prequalification of Contractors.

NOTE: INFORMATION PROVIDED IN THIS QUESTIONNAIRE IS NOT CONFIDENTIAL.

Prequalification Questionnaire (cont.)

INSTRUCTIONS TO APPLICANTS FOR PREQUALIFICATION

1.Any individual or organization that wishes to bid on a Department contract or to be approved as a subcontractor under any contract awarded by the Department must be prequalified by the Department.

2.As a prospective bidder or subcontractor you shall make yourself familiar with the Department’s rules for the prequalification of contractors (Chapter 1680-5-3), which may be obtained from the TDOT Construction Division by calling (615) 741-2414 or reviewed online at www.tdot.state.tn.us/construction/.

3.An application for prequalification must be filed on the Department’s Prequalification Questionnaire form. The Prequalification Questionnaire must be completed and submitted annually. Supplemental information may be required at the discretion of the Department.

4.This Prequalification Questionnaire must be filled out completely, and the truth and accuracy of the information provided must be certified by a sworn affidavit signed by an officer, partner, owner or other authorized representative of the applicant who has authority to sign contracts or other legal documents on behalf of the applicant.

5.The Prequalification Questionnaire must be filed with the Department at least fourteen (14) days prior to the date of any letting in which the applicant wishes to submit a bid to the Department, or at least fourteen (14) days prior to the date on which the applicant requests approval as a subcontractor under a contract awarded by the Department.

6.You are required to notify the Department if there is any subsequent change in the name, organization or contact information provided on the front page of this Questionnaire or if there is a subsequent change in the information provided in response to Questions 7 through 10 of this Questionnaire. (See TDOT Rule 1680-5-3-.04(4) for additional information on this requirement.)

7.Prequalification with the Department, if approved, is effective for a period of one year, plus a three-month grace period, beginning with the Fiscal Year End date shown on the front page of this Questionnaire. A new Prequalification Questionnaire may be filed at any time.

8.All questions in this Prequalification Questionnaire must be answered. Attachments are permissible to any page where there is not enough space provided.

9.To avoid delay, be sure that all information is provided and that all signatures are affixed and notarized where indicated. No questionnaire will be approved if any required signature or notary seal is omitted.

10.Upon completion of this Prequalification Questionnaire, send the completed form and all attachments to:

Tennessee Department of Transportation

Construction Division, Prequalification Office

505 Deaderick Street

Suite 700, James K. Polk Building

Nashville, TN 37243-0326

11.It is recommended that you keep a copy of this completed form for your records.

12.PLEASE NOTE: The Board for Licensing General Contractors is not a part of this Department and its licensing requirements are separate from this Department’s prequalification requirements.

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Prequalification Questionnaire (cont.)

ADDITIONAL INFORMATION

1.The Department reserves the right to request additional information and documentation to clarify and/or verify any information submitted in an applicant’s prequalification application.

2.The applicant may submit an audited financial statement, documentation of its maximum bonding capacity, or other financial information for the Department’s Prequalification Office to consider.

3.Additional information and/or documents requested by the Department or offered by the applicant will not be considered confidential except to the extent authorized or required by law.

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Prequalification Questionnaire (cont.)

GENERAL QUESTIONNAIRE

1.How many years has your organization been in business as a contractor under your present

business name?

______________________________________________

2.How many years of experience in construction work has your organization had?

	A. As a General Contractor			B. As a Subcontractor	_
(Question 3 is voluntary)
3.	a. Is your organization a minority owned or minority controlled business?
	yes	no
	b. What is the race of the majority owner?
	Caucasian			African American		Hispanic
	Other (please specify)			__________________

c.What is the gender of the majority owner?

male

female

4.Identify your firm’s gross annual receipts for most recent fiscal year (check appropriate range):

$0 - $500,000		$5,000,000 - $10,000,000
$500,000 - $1,000,000		$10,000,000 -$20,000,000
$1,000,000	- $2, 0000.00	$20,000,000 and greater
$2,000,000	- $5,000,000

5.Give the names and addresses of all surety bonding companies and agencies which have written surety bonds for you covering construction contracts during the last three (3) years.

Name of Bonding Company

Name of Agent

Agent Street Address

Agent City, State and Zip

Name of Bonding Company

Names of Agent

Agent Street Address

Agent City, State and Zip

6.Give the name, address and phone number of the person responsible for completing this Questionnaire.

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Prequalification Questionnaire (cont.)

AUTHORIZED SIGNATURES

7.Please provide the names and addresses of all individuals within your organization who are authorized to sign bid proposals and contracts on behalf of your firm. In the event any of these individuals is an officer, general partner or authorized representative of, or owns 10% or more of any other firm that is prequalified, or which has applied for prequalification, with the Department, please identify the affiliation or involvement with these other firms. The executed signature must be identical to signatures on future bid proposals submitted to the Department.

A.

Print Name

Signature

Position In Firm

Address

Involved in Another	Name of Other Firm	Position Held In Other	Financial Interest in Other Firm
Firm?		Firm

B.

Print Name

Signature

Position In Firm

Address

Involved in Another	Name of Other Firm	Position Held In Other	Financial Interest in Other Firm
Firm?		Firm

C.

Print Name

Signature

Position In Firm

Address

Involved in Another	Name of Other Firm	Position Held In Other	Financial Interest in Other Firm
Firm?		Firm

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Prequalification Questionnaire (cont.)

D.

Print	Name	Signature	Position In Firm		Address
yes	no
Involved in Another			Name of Other	Position Held In Other	Financial Interest in Other Firm
Firm?			Firm	Firm

E.

Print	Name	Signature	Position In Firm		Address
yes	no
Involved in Another			Name of Other	Position Held In Other	Financial Interest in Other Firm
Firm?			Firm	Firm

F.

Print	Name	Signature	Position In Firm		Address
yes	no
Involved in Another			Name of Other	Position Held In Other	Financial Interest in Other Firm
Firm?			Firm	Firm

G.

Print	Name	Signature	Position In Firm		Address
yes	no
Involved in Another			Name of Other	Position Held In Other	Financial Interest in Other Firm
Firm?			Firm	Firm

If additional space is needed, please make attachments to this page.

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Prequalification Questionnaire (cont.)

OFFICERS, PARTNERS AND OWNERS

8.In the table below, please provide the names and addresses of all officers of your firm (if any), all individuals or organizations that are general partners in your firm (if any), and all individuals or organizations that own 10% or more of your firm.

* Only if different from the address of the Applicant.

If additional space is needed, please make attachments to this page.

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Prequalification Questionnaire (cont.)

AFFILIATES

9.Use the table below to identify all affiliates of your firm.

Affiliate’s Name	Address	Percent	Affiliate’s Type of Work	Affiliate’s
		Ownership		Relationship to
				Applicant

If additional space is needed, please make attachments to this page.

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Prequalification Questionnaire (cont.)

BUSINESS RELATIONSHIPS OF OFFICERS, PARTNERS AND OWNERS

10.For each officer, general partner, and owner of your firm identified in response to Question 8 of this Questionnaire, use the table below to identify whether such officer, general partner, or owner is also an officer, general partner or authorized representative of, or owns 10% or more of, any other firm that is prequalified with or has applied for prequalification with the Department.

If additional space is needed, please make attachments to this page.

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Prequalification Questionnaire (cont.)

BUSINESS RELATIONSHIPS OF IMMEDIATE FAMILY MEMBERS

11.For each officer, general partner, owner, and authorized representative of your firm identified in response to Questions 7 and 8 of this Questionnaire, use the table below to identify whether such officer, general partner, owner, or authorized representative has an immediate family member (a spouse, mother, father, son, daughter, brother, or sister – including step, half and adoptive relationships) who is an officer, general partner, authorized representative, or owner of 10% or more of any other firm that is prequalified with or has applied for prequalification with the Department.

If additional space is needed, please make attachments to this page.

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Prequalification Questionnaire (cont.)

WORK CLASSIFICATIONS

12.Check all work classifications in which your company has prior experience and wishes to be given consideration for prequalification.

	ASPHALT PAVING		NON-ROADWAY CONSTRUTION – BUILDINGS,
			REST AREAS, ETC.
	BARRIERS-PARAPETS, CONCRETE BARRIERS, ETC.		PAVEMENT MARKING
	BASE – AGGREGATE BASES OR AGGREGATES		RIPRAP
	BRIDGE PAINTING		REMOVAL – BUILDINGS, STRUCTURES, ETC.
	CONCRETE PAVING		RAILROAD
	DRAINAGE – PIPE CULVERTS AND PRECAST BOXES		SALT BINS
	ENGINEERING		SCALES AND WEIGHING
	EROSION CONTROL		SLIPLINE PIPE
	EARTHWORK		SNOW AND ICE REMOVAL
	CONCRETE FLATWORK		STRUCTURES – BRIDGE
	FENCE		STRUCTURES – DRAINAGE
	GUARDRAIL/ATTENUATORS		SWEEPING AND DRAINAGE CLEANING
	INCIDENTAL OR MISCELLANEOUS ITEMS		TRAFFIC CONTROL – PERMANENT
	INTELLIGENT TRAFFIC SYSTEMS		TRAFFIC CONTROL - TEMPORARY
	LANDSCAPING – SEEDING, SODDING, TREES, ETC.		TUNNELS
	LIGHTING – ELECTRICAL, ETC.		UTILITIES
	MOWING AND LITTER REMOVAL		WALL – RETAINING WALLS

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Prequalification Questionnaire (cont.)

TYPE OF PREQUALIFICATION STATUS REQUESTED

13.Please indicate whether you are seeking a general or limited prequalification within the work classifications indicated in response to Question 12. (See TDOT Rule 1680-5-3-.05(2)(b) for additional information regarding the difference between general and limited prequalification status.)

(If limited please indicate the total number of contracts and/or aggregate amount of contracts that you would seek to perform at any given time.)

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Prequalification Questionnaire (cont.)

EXPERIENCE QUESTIONNAIRE

14. Current and recently completed contracts: Give adequate information to permit inquiry for references. Include all private and public projects.

								Status	Liquidated
	Contract			Classifications of Work		Completed on			Damages or
					Contract			(% Complete or
	Number or	Project Owner	Sub/Prime	Performed		Time?			Disincentives
					Amount			Date
	Project Number			(List as many as possible)					Assessed?
								Completed)
						yes	no		yes	no
						yes	no		yes	no
						yes	no		yes	no
						yes	no		yes	no
						yes	no		yes	no
						yes	no		yes	no
						yes	no		yes	no
						yes	no		yes	no
						yes	no		yes	no
						yes	no		yes	no
						yes	no		yes	no
						yes	no		yes	no

If additional space is needed, please make attachments to this page.

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Prequalification Questionnaire (cont.)

15. What is the construction experience of the principal individuals of your organization?
Name	Present Position/ Office Years Construction. Exp. Magnitude/ Type of Work	In What Capacity?

If additional space is needed, please make attachments to this page.

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Prequalification Questionnaire (cont.)

EQUIPMENT

16.List equipment owned by your firm, and then list separately equipment leased or otherwise available to you. Indicate whether the other firm from which you lease or otherwise obtain the equipment is prequalified with or has applied for prequalification with the Department. (You may attach your own equipment list in lieu of completing this page if all the required information is provided.)

If additional space is needed, please make attachments to this page.

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Prequalification Questionnaire (cont.)

CONTRACTOR RESPONSIBILITY

17.In the last five years has any of the following occurred?

A. The applicant or an affiliate associated with the applicant filed for bankruptcy.

B.The applicant or an affiliate associated with the applicant defaulted on or failed to complete a public contract or had a public contract terminated for cause.

C.The applicant or an affiliate associated with the applicant had a surety take over the payment or performance obligations of a public contract.

D.The applicant or an affiliate associated with the applicant had liens, claims or stop work orders filed against it on a public contract.

18.In the last five years has any of the following occurred?

A.The applicant, an affiliate of the applicant, or a general partner, owner, officer or authorized representative of the applicant (as identified in response to Questions 7 and 8 above) has been denied prequalification or has been suspended, debarred or otherwise excluded from bidding on or participating in any public contract by the Department or any other state, federal or local government agency.

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Prequalification Questionnaire (cont.)

B.The applicant, an affiliate of the applicant, or a general partner, officer, owner, or authorized representative of the applicant (as identified in response to Questions 7 and 8 above) has been convicted of, is currently under indictment for, or has been held liable in a civil judgment for any of the following:

(i)The commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public or private agreement or transaction.

(ii)A violation of Federal or State antitrust statues, including those prohibiting price fixing between competitors, allocation of customers between competitors, and bid rigging.

(iii)The commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, receiving stolen property, making false claims, or obstruction of justice.

(iv)The commission of any offense indicating a lack of business integrity or business honesty that seriously and directly affects such person’s or organization’s present responsibility.

C.The applicant, an affiliate of the applicant, or a general partner, officer, owner, or authorized representative of the applicant (as identified in response to Questions 7 and 8 above) has been convicted of or is currently under indictment for any criminal violation of the Federal Water Pollution Control Act; has been convicted of any criminal violation of the Tennessee Water Quality Control Act; or has been convicted of any criminal violation of any other state’s water quality or water pollution control act.

D.The applicant, an affiliate of the applicant, or a general partner, officer, owner, authorized representative of the applicant (as identified in response to Questions 7 and 8 above) received an enforcement order finding a violation of the Federal Water Pollution Control Act, the Tennessee Water Quality Control Act, or any other state’s water quality or water pollution control act.

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Prequalification Questionnaire (cont.)

AFFIDAVIT

_______________________________________________________________, being duly sworn, deposes

and says that he/she is _______________________________________________________________ of

(Title)

_____________________________________________________________________________________,

(Name of Applicant’s Organization)

and he/she further states that the answers to the foregoing questions and all statements therein contained are true and correct. A person who makes a false statement in this prequalification is subject to penalties of perjury.

By __________________________________________________________

Signature of Authorized Employee

The authorized employee, whose signature appears on this document, having personally appeared before me, and being sworn, deposes and says that the above statements are true and correct.

Sworn to and subscribed before me this _________ day of ______________________, _____________

___________________________________________________

(Notary Public)

My commission expires _____________ day of ___________________, _______________

(Seal)

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