How to Write an Acknowledgement Affidavit Letter - DOC

							                          MIAMI-DADE COUNTY – OFFICE OF CAPITAL IMPROVEMENTS (OCI)
                             ARCHITECT-ENGINEER LETTER OF QUALIFICATIONS (LOQ)

                                                  (I) - PROJECT INFORMATION
OCI Pro ject No.: E10-JMH-03 Measures 12.5 %  Goal   Set-Aside                CBE    DBE       No. of Addenda Received:
Project Name: FIRE ALARM UPGRADES AT JACKS ON MEMORIAL HOS PITAL


Firm No. 1                               (II) - PRIME CONSULTANT INFORMATION
 Name:                                                           FEIN:              E-mail:
 Business Address:                                               Principal:                           Phone: (     )       -
 Contact Person’s Name and Title:                                Project Manager:                       Fax: (     )       -
 Assigned Personnel:




Firm                               (III) - PROPOSED A/E SUB-CONSULTANT(S) INFORMATION
 No.                               Firm Name                       FEIN                    Assigned Personnel
  2
  3
  4
  5
  6
  7
  8

                                (IV) – A/E TECHNICAL CERTIFICATION REQUIREMENTS
          A/ E Technical Certification Category                                                      Prime         Sub-
 13.00        General Electrical Engineering (PRIME)                                                             Consultant
 17.00        Engineering Construction Management (PRIME)
 14.00        Architecture




No.                          (V) - PROPOSED NON-A/E SUB-CONSULTANT(S) INFORMATION
       Firm Name:                                                                    FEIN:             Phone: (        )       -
       Address:
       Assigned Personnel:
a
       Assigned Services:



       Firm Name:                                                                    FEIN:             Phone: (        )       -
       Address:
       Assigned Personnel:
b
       Assigned Services:




Page 1 of 2                                                                                               LOQ Form - Rev. 3-12-10
                             (VI) - AB ILITY OF TEAM MEMB ERS TO INTERFACE WITH THE COUNTY




                                       (VII) - RES UMES FOR ASSIGNED PERSONNEL
Attach two page resumes for all team members.

                    (VIII) - LOCAL CERTIFIED S ERVICE-DISAB LED VET ERAN B US INESS ENTERPRIS E
A Local Cert ified Service-Disabled Veteran Business Enterprise is a firm that is a) a local business pursuant to Section 2-8.5 of the Code
of Miami-Dade County and b) is certified by the State of Florida Department of Management Services as a Service-Disabled Veteran
Business Enterprise pursuant to Section 295.187 of the Florida Statutes, prior to proposal submittal. At the time of proposa l submission,
the Local Certified Serv ice-Disabled Veteran Business Enterprise must affirm in writing its compliance with the certification
requirements of Section 295.187 of the Florida Statues and submit said affirmation and a copy of the actual certification alo n g with the
proposal submission.

              Place a checkmark here only if affirming proposer is a certified Local Cert ified Serv ice -Disabled Veteran Business Enterprise.
              A copy of the required certification must be submitted with the proposal.

THE EXEC UTION OF THE LOQ CONSTITUT ES THE UNEQUIVOCAL OFFER OF PROPOS ER TO B E BOUND BY THE
TERMS OF HIS OR HER PROPOSAL. FAILURE OF AN AUTHORIZED PRIME FIRM REPRES ENTATIVE TO S IGN
THIS LOQ WHER E INDICATED B ELOW, MAY RENDER THE PROPOSAL NON -RESPONS IVE. HOW EV ER, THE
COUNTY MAY, AT ITS SOLE DISCRETION, ACCEPT ANY PROPOSAL THAT INCLUDES AN EX ECUT ED
DOCUMENT WHICH UNEQUIVOCALLY B INDS THE PROPOS ER TO THE TERMS OF HIS OR HER OFFER.

                                            (IX) - PRIME CONS ULTANT ACKNOWLEDGEMENT
I hereby certify that to the best of my knowledge and belief all the foregoing information is true and correct.

Authorized Prime Consultant’s Representative:                                                      Tit le:
                                                                     (Print Name)

Signature Authorized Representative: ______________________________________________ Date:



                                           FOR MIAMI-DADE COUNTY – OCI USE ONLY
                                               DO NOT WRITE IN THIS SECTION
                                        A/E TECHNICAL CERTIFICATION REQUIREMENTS
 TC #               Team               Pre Q               TC                                   Addi tional Comments
                      Membe      Yes         No
                                         fffffVer    Yes     No
                        rs       Yes         No
                                          ificatio   Yes     No
                                 Yes          n
                                             No      Yes     No
                                 Yes         No      Yes     No
                                 Yes         No      Yes     No
                                 Yes         No      Yes     No
                                 Yes         No      Yes     No

                                            FOR MIAMI-DADE COUNTY – OCI USE ONLY
                                                 DO NOT WRITE IN THIS SECTION
                                            OCI FORMS AND OTHER DOCUMENTATION
Forms                                                             Verificati on                              Addi tional Comments
OCI Form 6 Reference                                              Yes      No
OCI Form 7 Reference                                              Yes      No       N/A
OCI Form 8 Reference                                              Yes      No       N/A
Table of Organizati on                                            Yes      No
OCI Form 3 – Local Business Preference Affi davit                 Yes      No       N/A
OCI Form 5 – Lobbyist Registration Affi davit                     Yes      No
Completed CB E Forms and/ or documentati on                       Yes      No       N/A

Page 2 of 2                                                                                                                   LOQ Form - Rev. 3-12-10