Contractor Prequalification

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					                   JEFFERSON COUNTY SCHOOL DISTRICT NO. R-1
                                CONTRACTOR
                        PRE-QUALIFICATION STATEMENT

1.0    Specify contract(s) requesting to be pre-qualified for: Select from list

2.0    Provide Firm Information, local office and principle office if other than local office designated:
        Contact Person:
        Current Legal Name:
        Street Address:
        City/State/Zip:
        Telephone Number:
        Fax Number:
        E-mail Address:

        2.1      How many years has your firm been in business?

3.0    Please check the appropriate box to identify the nature of your firm.

              Corporation                              Partnership
              Other                                    Individual

        3.1      Provide an organizational chart for your firm.

        3.2      Corporations: provide a copy of the most recent Annual Report
                 Date firm Incorporated
                 State where firm is incorporated
                 County where firm is incorporated
                 Name of President
                 Name of Vice President(s)
                 Name of Secretary
                 Name of Chief Financial Officer

        3.3      Partnership or individual: provide the following information.
                 Date firm established
                 Name and address of individual/partners (Indicate partners and whether general or limited
                 partners).
                 Name                             Address




        3.4      Other types of firms: list the names and addresses of principals.



4.0    What type of work and approximately what percentage of work would be performed by your
       own forces on this project?
              Type                 Percentage
              General



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                   JEFFERSON COUNTY SCHOOL DISTRICT NO. R-1
                                CONTRACTOR
                        PRE-QUALIFICATION STATEMENT




5.0    Has your firm failed to accept a contract award or to complete a contract awarded to you? No
        If your response was "yes" to the previous question please, state the project(s), date, owner
       and reason.


6.0    Has your firm ever had a contract terminated?     No    If "yes", state the project(s), date,
       owner and reason.


7.0    Bonding Information:
        Name of bonding company
        Bests Rating
        Bests Financial Rating
        Name and address of bonding company agent

        Bonding Capacity:         Maximum Bonding Value $
                                  Current Value of bonded Projects $

8.0    Has your bonding company ever been required to perform or complete work under a bid bond,
       labor and material payment bond, or performance bond issued on your firm's behalf? No If
       "yes", state the project(s), date, owner and reason.



9.0    Within the last five years has your current firm or any predecessor organization been involved
       as a party in any bankruptcy, litigation or arbitration proceedings? No If your response to the
       previous question was "yes", please attach a separate sheet with explanation.

10.0   Within the past two (2) years has your firm or predecessor firm received a Notice of Violation
       and/or Non-compliance notice from any Local Municipality, State or Federal agency? No If
       your response to the previous question was "yes", please attach a separate sheet with
       explanation.

11.0   Current Work: On a separate page list the projects your firm has completed in the past five
       years or currently has in progress stating the name of the owner and telephone number, name of
       project, brief project description, the name of the architect and telephone number, location of
       project, original contract amount, current contract amount, percentage of completion, and
       scheduled completion date.

12.0   Resumes: Provide on separate sheets of paper, resumes/experience for key staff in your firm
       including project managers, superintendents, estimators, schedulers or others that will work on
       JeffCo projects. For Project Manager and Superintendent include how long employee has been
       with your firm and project reference contact information for past five years projects.

13.0   Provide a list of individuals in your company who have received training in Stormwater
       Management Planning. Attach a copy of the certificate for each individual.


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                   JEFFERSON COUNTY SCHOOL DISTRICT NO. R-1
                                CONTRACTOR
                        PRE-QUALIFICATION STATEMENT


14.0   Does your firm have a company wide safety program? Yes

        14.1     Is a copy of the safety program available to JeffCo for examination?           Yes

        14.2     Attach a sample site specific safety plan.

        14.3     Does your firm have a safety officer? Yes If so, attach a resume.

15.0   What is your current experience modification rate (EMR) for Worker's Compensation?

16.0   Does your firm provide a bona fide health benefit & retirement plan for your employees? Yes

        16.1     What percentage of your current employees is covered by your plan?
        16.2     Is a copy of your health benefit and retirement plan available to JeffCo for
                 examination? Yes

17.0   Does your firm have a pre-hire criminal background program? Yes

18.0   Does your firm have a pre-hire drug-testing program? Yes

       18.1      Does your firm require that subcontractors working on your project have a pre-hire
                drug-testing program? Yes

        18.2     Does your firm have a policy to insure a drug free work place? Yes

        18.3    Is a copy of the procedure to enforce this policy available to JeffCo for examination?
            Yes

19.0   Does your firm participate in an affirmative action program? Yes

        19.1     Is a copy of the Affirmative Action Program available to JeffCo for examination? Yes

20.0   Attach a financial statement, preferably an audited statement, including your firm's latest
       balance sheet and income statement showing the following items:
        Current Assets, Net Fixed Assets, Other Assets, Current Liabilities, Other Liabilities
        Name of firm preparing financial statement and date prepared.
        Explain any difference between firm for which financial statement was prepared and firm
           listed in section 2.0 of this statement (e.g., parent, subsidiary, joint venture, etc.)

        20.1     Bank References; name and contact information.




        20.2     Trade and/ or Vendor References; name and contact information




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                    JEFFERSON COUNTY SCHOOL DISTRICT NO. R-1
                                 CONTRACTOR
                         PRE-QUALIFICATION STATEMENT


I hereby certify that the information provided in this statement is true and correct.

                                      By                                  Title
Print Name


Date


State of Colorado

County of

The foregoing statement was acknowledged before me this              day of        , 20

by          as

of

My commission expires


Witness by hand and official seal                                                         Notary



                                                                                          Address




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