Aia Contractor Pre Qualification Form a305 by zde17276

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									C&T/AW JV SUPPLEMENTAL INFORMATION TO THE AIA A305 CONTRACTOR’S QUALIFICATION STATEMENT

                                        Please complete the following and return to:



Construction Manager at Risk:      Clancy & Theys/Archer Western Joint Venture
Address:                           516 West Cabarrus Street, Raleigh, NC 27603
Contact:                           Jen Street
Telephone:                         919-834-3601 x283
Fax:                               919-834-2439
Email:                             jenstreet@clancytheys.com

Project:          Clarence E. Lightner Public Safety Center

Company Name:
Physical Address, City, St, Zip:
Estimator in Charge:
                                   Please identify the person who should receive all notifications of addenda, clarifications,
                                   etc. for this project during bidding.
Telephone:
Fax:
E-mail Address:
Number of years in business under present business name:

Requesting pre-qualification for the following bid package(s) (more than one may be chosen

           02S-Design/Build Shoring

Additional Business Information:
Please check any of the following that apply to your organization and attach documentation from any local, state, or
federal agency that has certified your firm as such:

     African American Owned                                             American Indian Owned
     Hispanic Owned                                                     Woman Owned
     Asian American (incl. Pacific Islander) Owned                      None Apply

Additional Bonding and Construction Capacity Information:
Current Bond Company Rating:
Present Bonding Capacity – Aggregate:                                            $
Current Amount Available – Aggregate:                                            $
Bonding Capacity – Per-Project Limit:                                            $
Value of work in place for the year 2008:                                        $
Value of work in place for the year 2009:                                        $
Value of largest contract completed:                                             $
List the Minimum job value in which you prefer to perform work:                  $
List the Maximum job value in which you prefer to perform work:                  $
Percent (%) of work performed by own forces:                                             %
Total number of permanent staff presently employed by your firm:




                                         CLANCY & THEYS/ARCHER WESTERN JOINT VENTURE
                                            SUPPLEMENTAL QUALIFICATION STATEMENT
                                                         Page 1 of 3
Please attach a list of your firm’s current/upcoming projects, including the following information: Project,
Location, General Contractor/Owner, Scope of Work, Contract Amount, Percentage Complete, and Anticipated
Start and Completion Date(s).

Experience Information (Completed Projects):
List three (3) project references of similar experience relative to this project.
      A. Name of Project:
         Contract Amount:
         Scope of Work:
         General Contractor/Owner:
         Contact Name:
         Phone:
      B. Name of Project:
         Contract Amount:
         Scope of Work:
         General Contractor/Owner:
         Contact Name:
         Phone:
      C. Name of Project:
         Contract Amount:
         Scope of Work:
         General Contractor/Owner:
         Contact Name:
         Phone:

Additional Reference Information:
List three (3) contractor or owner references:
      A. Company Name:
         Contact Name:
         Address:

          Phone:
      B. Company Name:
         Contact Name:
         Address:

          Phone:
      C. Company Name:
         Contact Name:
         Address:

          Phone:




                                         CLANCY & THEYS/ARCHER WESTERN JOINT VENTURE
                                            SUPPLEMENTAL QUALIFICATION STATEMENT
                                                         Page 2 of 3
Environmental, Health, and Safety Issues:
List your firms Worker’s Compensation Insurance Interstate/Intrastate Experience Modification Rate (EMR) for the past
4 years indicated. 2005:      2006:        2007:        2008:        , Average
NOTE: If EMR Average for the last four (4) years is over 1.0, submit an OSHA 200 Log for each year with response.
Does your firm have a(n)...
        - written safety and environment program?                                      YES             NO
        - written substance abuse program/policy?                                      YES             NO
        - instruction program for New Hires and/or Foreman?                            YES             NO
Have you had any OSHA Fines within the last 3 years?                                   YES             NO
Have you had any job related fatalities within the last 3 years?                       YES             NO

(If you answered YES to either of the above two (2) questions, submit on a separate sheet, the details describing the
circumstances surrounding each incident.)

Project Staffing and Procurement History:
On a separate sheet, list the names, project experience, responsibilities, & duties of personnel who will be responsible
for this project, including at a minimum, the Project Manager, Field Superintendent, & Foreman.

(If contractor is successful bidder, the name of the above personnel may become a part of the contract documents.)

Indicate how your firm obtains most of its work (bid, negotiated, etc.)

Has your firm ever participated in a project utilizing the CM at Risk approach?        YES             NO

Insurance Information:
Insurance Company:
Agent Company:
Telephone:
Fax:

Please attach copy of insurance certificate.




                                        CLANCY & THEYS/ARCHER WESTERN JOINT VENTURE
                                           SUPPLEMENTAL QUALIFICATION STATEMENT
                                                        Page 3 of 3

								
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