HICAPS

"I guess the best compliment that you can give someone is that you created enthusiasm and excitement about making our scheduling program more effective. You were the talk at the water cooler this morning. Thank you so much. You did an excellent job and we are all appreciative."

Kathy T. Pigg
Executive Vice President
Brindley Construction Group

Please fill out this form and submit, and don't forget to download a W9.

Firm Name:

Areas you are willing to work:

Services Performed:

Mailing Address

Mailing Address:

Mailing City:

Mailing State:

Mailing Zip:

Shipping Address

Shipping Address:

Shipping City:

Shipping State:

Shipping Zip:

Phone:

Fax:

Web Site Address:

Point of Contact:

POC Phone Number:

POC Email:

Contractor's License Number:

Type:

State:

Class

Does your firm meet any of the following criteria:

SDVOSB

VOSB

HUB

DBE

MBE

WBE

SWAM

8(a)

Year Business Established:

Annual sales volume:

Number of employees:

Dun & Bradstreet Number:

Does your firm have union affiliations?

Yes No

Can your firm provide bonds?

Yes No

Current Workers Compensation Experience Modification Rate Factor (EMR):

Is the firm now, or has it ever been involved in bankruptcy proceedings?

Yes No

Is the firm now, or has it ever been involved in reorganization proceedings?

Yes No

Are there any pending or outstanding judgements, claims, or suits?

Yes No

Has your firm ever failed to complete a contract?

Yes No

Has your firm ever been terminated on a contract for cause?

Yes No

Within the last 5 years, has your firm made payment of actual and/or liquidated damages for failure to complete a project by the contracted date?

Yes No

Has your organization, in the last three years, received a final order for willful and/or repeated violation(s) for failure to abate issued by the United States Occupational Safety and Health Administration or by the Virginia Department of Labor and Industry or any other government agency?

Yes No

Have any Performance or Payment Bond claims ever been paid by any surety on behalf of your organization?

Yes No

In the last ten years, has your organization, or any officer, director, partner or owner, had judgments entered against it or them for the breach of contracts for construction?

Yes No

In the last ten years, has your organization or any officer, director, partner, owner, project manager, procurement manager or chief financial officer of your organization:

A. Ever been fined or adjudicated of having failed to abate a citation for building code violations by a court or local building code appeals board?

Yes No

B. Ever been found guilty on charges relating to conflicts of interest?

Yes No

C. Ever been convicted on criminal charges relating to contracting, construction , bidding, bid rigging or bribery?

Yes No

D. Ever been convicted: (i) under Va. Code Section 2.2-4367 et seq. (Ethics in Public Contracting); (ii) under Va. Code Section 18.2-498.1 et seq. (Va. Governmental Frauds Act); (iii) under Va. Code Section 59.1-68.6 et seq. (Conspiracy to Rig Bids); (iv) of a criminal violation of Va. Code Section 40.1-49.4 (enforcement of occupational safety and health standards); or (v) of violating any substantially similar federal law or law of another state?

Yes No

Is your organization or any officer, director, partner or owner currently debarred from doing federal, state or local government work for any reason?

Yes No

Comments:

Provide the following information on three projects you are working on or have completed in the past 3 years:

Project 1
Project 1 Name/Location:
Description of your work:
Your Contract Amount:
Owner or General Contractor:
Contact:
Position:
Phone:

Project 2
Project 2 Name/Location:
Description of your work:
Your Contract Amount:
Owner or General Contractor:
Contact:
Position:
Phone:

Project 3
Project 3 Name/Location:
Description of your work:
Your Contract Amount:
Owner or General Contractor:
Contact:
Position:
Phone:

By submitting this form, I affirm and certify that the information contained herein is accurate, and also entitle HICAPS, Inc. to contact references and names contained in this questionnaire.