Full Text
Revised March 2022 INSTRUCTIONS FOR COMPLETING THE OREGON DEPARTMENT OF TRANSPORTATION PRIME CONTRACTOR PREQUALIFICATION APPLICATION To be eligible to bid, an application must be completed in its entirety and received at least 10 calendar days before the bid opening in which the applicant wishes to participate (per OAR [PHONE REDACTED](9)). Allow 30 days for processing. Forms and instructions are available online at: Before moving on to the application, please print the instruction page and use when filling out your application to ensure accurate completion. GENERAL INFORMATION • All pages and sections must be completed and correct. If not, the application will be returned by mail to the applicant for correction. • Do not use correction fluid or correction tape. • If accepted, an approval letter will be sent. • Submit the correct form. Outdated forms or pages will not be accepted. Go to the Construction website to find the CURRENT form (link above). • Send original signed application. Copied or faxed signatures will not be accepted. Signatures preferred in blue ink. • Prequalification is required for prime contractors. Subcontractors/suppliers do not need to prequalify. • To make changes to an application, see website for instructions (link above). • If a section does not apply, enter Page 1 A. Enter today's date. ODOT will notify you of your expiration date in your prequalification approval letter. B. Application of: Enter the legal name under which you wish to bid as it appears on your federal form W-9 (Request for Taxpayer Identification Number and Certification). An assumed business name (complete Section 6) is not a legal name; however, it can be used in conjunction with a legal name when prefaced by "dba." A separate Prequalification Application is required for each separate legal entity. C. Mark your business structure. D. If application is for a joint venture, mark the appropriate box. Contact ODOT (contact information on the bottom right side of page) for additional information. E. Mark the purpose(s) of your application and the first anticipated bid opening date, if known. F. Provide your physical address for courier use (no P.O. Boxes). Provide your mailing address, phone, fax number, business email address and a contact person. Provide contact information for person completing application. Also, provide contact information for the name to appear on Planholders list. Pages 2-6 Sections 1, 2, 3, 4, 5 and 6, fill out as applicable, Business Structure: If you have an assumed business name you must complete Section 6. If you make a change in officers during the year, you must submit an addendum change form to ODOT. See our website for instructions on how to make changes (link above). Page 9 Section 9, Supplemental Questions: Mark all questions as they apply to the company AND to its owners, officers, partners and principal individuals. Page 10 Section 10, Classes of Work: Check beside each class of work for which you have demonstrated the experience in and those you wish to add. This experience may be your own work force or through project management of subcontractors. List all other states where you are currently qualified or have been qualified in the last three years. You may list "OTHER" (OTH1) classes of work; however, ODOT does not normally solicit bids under this class. This class of work is typically used by local agencies (cities, counties, etc.) A detailed list of Bid Items for each work class can be found at the following link: List.xlsx **REFERENCES for Class(es) of Work: A new applicant prequalifying, a prequalified applicant who wishes to add a new class or classes of work in which they have not been previously prequalified, or companies prequalification has lapsed for longer than 6 months, must provide at least three references for each new Class of Work. Project(s) must be completed within the last 5 years. Reference instructions and forms can be found at the link at the top of the page. Page 11 Section 11 & 12: List years of experience and experience of owners, officers, partners and other key individuals in organization. Section 13: Space to provide additional information. Page 12 Section 14, Affidavit: Signature must be of an individual who is authorized to execute bids and/or contracts. The affidavit must be notarized. Mail Application and W-9 to: Oregon Department of Transportation Construction Contracts Unit MS #5-1 355 Capitol St NE Salem, OR 97301 Questions? Call [PHONE REDACTED] ---PAGE BREAK--- Prime Contractor Prequalification Application Page 1 Revised June 2022 OREGON DEPARTMENT OF TRANSPORTATION PRIME CONTRACTOR PREQUALIFICATION APPLICATION Submit application to: Oregon Department of Transportation ODOT Procurement Office – Construction Contracts Unit, MS #5-1 355 Capital St. NE Salem, OR 97301 Phone: [PHONE REDACTED] Website: www.oregon.gov/odot/business/procurement/pages/index.aspx FSB Date Initials A. Date: Expiration Date: Enter today’s date (To be completed by ODOT) B. Application of: Legal Business Name (as shown on your federal form W-9) Assumed Business Name(s) (Complete Section 6) List previous business names of your organization: E. Purpose of Application (Check all that apply): C. Business Structure (Check one): Oregon Corporation Foreign Corporation Limited Liability Company (LLC) Limited Liability Partnership (LLP) Limited Partnership (LP) General Partnership Individual Sole Proprietorship D. Joint Venture ODOT Projects 1st anticipated bid opening date Local Government Projects 1st anticipated bid opening date Other Government Projects 1st anticipated bid opening date F. Address: Physical address, city, state, zip (No P.O. Boxes) Mailing address, city, state, zip Phone Fax PERSON COMPLETING APPLICATION: Name Phone Email Fax PERSON TO APPEAR ON PLANHOLDERS LIST (attach additional sheets if necessary): Name Phone Email Fax To be completed by ODOT: RECEIPT DATE #1 RECEIPT DATE #2 RECEIPT DATE #3 RECEIPT DATE #4 SOS / CCB / CCB / BOLI / SAM APPROVAL/LAST RECPT DATE / INIT ADD #1 / INIT______ DESC: REVIEW DATE / INIT ELIGIBILITY DATE ADD #2 / INIT______ DESC: VENDOR NO. DATA ENTRY DATE / INIT CHECK SENT TO FSB: / INIT ---PAGE BREAK--- Prime Contractor Prequalification Application Page 2 Revised June 2022 BUSINESS STRUCTURE: Complete section 1, 2, 3, 4, or 5 as applies 1 If an Oregon corporation, complete this section NA Date Corporation was registered with Secretary of State President Secretary 1st Vice President Treasurer CONTRACT EXECUTION - List of Authorized Personnel A) President and Secretary (Both President and the Secretary of the corporation are required to sign ODOT contracts and performance and payment bonds unless certified, true and correct copy of corporate bylaws, resolutions, or minutes state otherwise and are attached to this prequalification.) Signatures are preferred in blue ink. Printed name of President Signature Printed name of Secretary Signature B) Are other officers besides the President and Secretary of your company authorized to execute contracts? Yes No If yes, list below and attach certified, true and correct copy of corporate bylaws, resolutions, or minutes stating that authority. Printed name and title Signature Printed name and title Signature Printed name and title Signature Printed name and title Signature C) Are any of the officers (listed above in A & B) authorized to sign and execute contracts and bonds on behalf of the company without the signature of others? Yes No IF YES, YOU MUST ATTACH CORPORATE BYLAWS, RESOLUTIONS, OR MINUTES STATING THIS AUTHORITY TO SIGN ALONE ON BEHALF OF THE CORPORATION. BID EXECUTION - List of Authorized Personnel Signatures of all individuals (INCLUDING ANY OFFICERS LISTED ABOVE) authorized to execute Bids on behalf of the company shall be listed in this section, including any officers listed above and those individuals with a digital ID used for submitting an electronic bid through BidExpress®. Signatures are preferred in blue ink Printed name and title Signature Printed name and title Signature Printed name and title Signature Printed name and title Signature (Additional documentation may be required by the public contracting agency) ---PAGE BREAK--- Prime Contractor Prequalification Application Page 3 Revised June 2022 2 If a foreign (out of state) corporation, complete this section NA When incorporated President Secretary 1st Vice President Treasurer CONTRACT EXECUTION - List of Authorized Personnel A) President and Secretary (Both President and the Secretary of the corporation are required to sign ODOT contracts and performance and payment bonds unless certified, true and correct copy of corporate bylaws, resolutions, or minutes state otherwise and are attached to this prequalification.) Signatures are preferred in blue ink Printed name of President Signature Printed name of Secretary Signature B) Are other officers besides the President and Secretary of your company authorized to execute contracts? Yes No If yes, list below and attach certified, true and correct copy of corporate bylaws, resolutions, or minutes stating that authority. Printed name and title Signature Printed name and title Signature Printed name and title Signature Printed name and title Signature C) Are any of the officers (listed above in A and B) authorized to sign and execute contracts and bonds on behalf of the company without the signature of others? Yes No IF YES, YOU MUST ATTACH CORPORATE BYLAWS, RESOLUTIONS, OR MINUTES STATING THIS AUTHORITY TO SIGN ALONE ON BEHALF OF THE CORPORATION. BID EXECUTION - List of Authorized Personnel Signatures of all individuals (INCLUDING ANY OFFICERS LISTED ABOVE) authorized to execute Bids on behalf of the company shall be listed in this section, including any officers listed above and those individuals with a digital ID used for submitting an electronic bid through BidExpress® Signatures are preferred in blue ink Printed name and title Signature Printed name and title Signature Printed name and title Signature Name and address of registered agent in Oregon: Date of authorization by Oregon Secretary of State to transact business in Oregon: Has applicant filed with Oregon Department of Revenue (DOR) forms required by ORS 279A.120? Yes No Sec. of State Phone: [PHONE REDACTED] Website: www.filinginoregon.com Department of Revenue Phone: [PHONE REDACTED] Website: www.oregon.gov/dor/pages/ind ex.aspx ---PAGE BREAK--- Prime Contractor Prequalification Application Page 4 Revised June 2022 3 If a limited liability company, limited liability partnership or a limited partnership complete this section NA Check One: Limited liability company Limited liability partnership Limited partnership Have you registered with the Oregon Secretary of State, Corporation Division, Business Registry? Yes No Name and address of organizer: SUBMIT ARTICLES OF ORGANIZATION AND OPERATING AGREEMENTS THAT INDICATE THE AUTHORITY TO SIGN CONTRACTS AND BONDS. If the Contractor is an LLP, or LP, an authorized representative of each Entity comprising it shall sign the Contract, Performance Bond, and Payment Bond. If any representative is authorized to execute contracts without the signature of others, this must be stated in the Articles of Organization and Operating Agreements. Printed names, titles and signatures (Signatures are preferred in blue ink) of personnel authorized to EXECUTE CONTRACTS: Printed name and title Signature Printed name and title Signature Are other representatives besides those listed above able to execute contracts? Yes No If yes, submit names, titles and signatures separately. Printed names, titles and signatures of personnel authorized to EXECUTE BIDS Signatures of all individuals (INCLUDING ANY OFFICERS LISTED ABOVE) authorized to execute Bids on behalf of the company shall be listed in this section, including any listed above and those individuals with a digital ID used for submitting an electronic bid through BidExpress®. Signatures are preferred in blue ink. Printed name and title Signature Printed name and title Signature Printed name and title Signature Printed name and title Signature Printed name and title Signature ---PAGE BREAK--- Prime Contractor Prequalification Application Page 5 Revised June 2022 4 If a general partnership, complete this section NA Date of Organization If a foreign (out of state) co-partnership or persons engaging in business in the state under an assumed name, but not domiciled within this state, is the partnership or business organization registered as required in compliance with ORS 648 et. seq? Yes No N/A Names and addresses of partners: If the Contractor is a partnership or limited liability partnership, an authorized representative of each Entity comprising it shall sign the Contract, Performance Bond, and Payment Bond, and an authorization to sign shall be attached. If only one partner is signing, then bylaws or minutes must include the authority to sign without the signature of others. Printed names, titles and signatures of partners authorized to EXECUTE CONTRACTS. Signatures are preferred in blue ink. Printed name of partner Signature Printed name of partner Signature Bylaws or Minutes Submitted: (Check one) Yes No (Only submit if signatures differ from above) Printed names, titles and signatures of personnel authorized to EXECUTE BIDS Signatures of all individuals (INCLUDING ANY OFFICERS LISTED ABOVE) authorized to execute Bids on behalf of the company shall be listed in this section, including any officers listed above and those individuals with digital ID used for submitting an electronic bid through BidExpress®. Signatures are preferred in blue ink. Printed name and title Signature Printed name and title Signature Printed name and title Signature Printed name and title Signature (Additional documentation may be required by the public contracting agency) ---PAGE BREAK--- Prime Contractor Prequalification Application Page 6 Revised June 2022 5 If doing business as a sole proprietorship, complete this section NA Name of individual liable for all obligations of the business: If applicant is a sole proprietor using an assumed business name, please list name below: Secretary of State registration date: Expiration date: Printed name and title Signature (Additional documentation may be required by the public contracting agency) 6 If doing business under an assumed business name, complete this section NA Assumed business name: Owner's name and address: Oregon Secretary of State Corporation Division’s Registration Number: Renewal Date: Assumed business name: Owner's name and address: Oregon Secretary of State Corporation Division’s Registration Number: Renewal Date: If you have additional assumed business names, attach a sheet with business information. ---PAGE BREAK--- Prime Contractor Prequalification Application Page 7 Revised June 2022 7 OWNERSHIP AND CONTROL B, and C) A) Are there any parent companies, corporations, or individuals with at least 10% ownership interest in applicant's firm? Yes No If yes, please list below in space provided B) Are there any subsidiary companies or corporations owned or controlled by the applicant doing business in Oregon under another name? For the purposes of this information, the applicant includes the applicant’s officers, directors, or partners, or other entity in which the applicant is an officer, director, or partner. Yes No If yes, please list below in space provided C) Are there any other personnel in applicant's organization who have a financial interest in or serve as officers or partners in another firm prequalified to bid in this or another state? Yes No If yes, please list below in space provided. Individual's Name Present Position or Office Other Firm or Firms Position in Other Firm(s) State of Other Firm(s) ---PAGE BREAK--- Prime Contractor Prequalification Application Page 8 Revised June 2022 8 LICENSES AND REGISTRATIONS Required for Legal Business Name, Assumed Business Name (page 1, Section Corporations, LLCs, LLPs, and LPs. Required prior to contract execution. Required prior to bid opening for state-funded projects or prior to contract execution for federally-funded projects (not required for Aggregate Production or Landscaping work categories). Required with all Applications. Oregon Secretary of State Corporation Division – Active Business Registry No.: Phone: [PHONE REDACTED] Oregon Construction Contractors Board No.: www.oregon.gov/CCB/Pages/Index.aspx Phone: [PHONE REDACTED] W-9 Taxpayer Identification Number: Submit a current dated W-9 with application. Oregon Business Landscape Contractors License No. and company name: Individual Landscape Contractor License No. and name: www.oregon.gov/LCB/pages/index.aspx Phone: [PHONE REDACTED] Oregon Electrical Contractor License No. and company name: Supervisor’s License No. and name : www.oregon.gov/BCD/pages/index.aspx Building Codes Division phone: [PHONE REDACTED] Oregon Plumbing Business License No. and company name: Journeyman’s License No. and name: Oregon Boiler/Pressure Vessel Business License No. and company name: www.oregon.gov/BCD/pages/index.aspx Building Codes Division phone: [PHONE REDACTED] Other License No. and name or type: ---PAGE BREAK--- Prime Contractor Prequalification Application Page 9 Revised June 2022 9 SUPPLEMENTAL QUESTIONS A) Within the last five years has the applicant, or any parent, subsidiary or affiliate, been denied prequalification or had prequalification suspended or revoked by any state, local or federal agency in this or any other state? Yes No If yes, please attach an explanation. B) Within the last five years has the applicant, or any parent, subsidiary or affiliate, been debarred from bidding on contracts by any state, local or federal agency in this or any other state under any state or federal law? Yes No If yes, please attach an explanation. C) Has any officer or partner of the applicant, or of any parent, subsidiary or affiliate, ever applied for prequalification with ODOT under a different name? Yes No If yes, please attach an explanation. D) Within the last five years has the applicant, or any parent, subsidiary or affiliate, failed to complete a state, local or federal public improvement (works) contract? Yes No If yes, please attach an explanation. E) Within the last five years has any officer or partner of the applicant, or of any parent, subsidiary or affiliate, been found in breach of a local, state or federal contract? Yes No If yes, please attach an explanation. F) Within the last five years has the applicant, or any officer, partner, agent or employee of applicant, or any parent, subsidiary or affiliate, been found to have violated any state or federal prevailing wage statute or regulation (including the federal Davis-Bacon and related Acts and ORS 279C.800 et. seq.), or any provision requiring prompt payment to subcontractors, in any Final Order of the Oregon Bureau of Labor and Industries or the United States Department of Labor, by any other state or federal agency, or by any court of competent jurisdiction? Yes No If yes, provide copies of the final order(s) or judgment in which this occurred and explain in detail: the circumstances behind any violation, including the amount(s) not paid whether the amount(s) have now been paid the reasons for the violation all efforts undertaken to ensure that future violations will not occur G) Within the last five years has the applicant, or any officer, partner, agent or employee of applicant been found to have violated any state or federal environmental statute or regulation (including but not limited to Environmental Protection Agency, Department of Environmental Quality, US Fish and Wildlife Service, Department of Fish and Wildlife, US Army Corps of Engineers, Division of State Lands, Department of Agriculture or Department of Interior), or any permit issued by one of these agencies, in any agency Final Order or by any court of competent jurisdiction? Yes No If yes, provide copies of the final order(s) or judgment in which this occurred and explain in detail: the circumstances behind any violation, including the amount(s) not paid whether the amount(s) have now been paid the reasons for the violation all efforts undertaken to ensure that future violations will not occur Comments: ---PAGE BREAK--- Prime Contractor Prequalification Application Page 10 Revised June 2022 10 CLASSES OF WORK Fill in the classes of work on which you wish to be pre-qualified to bid. Classes of work include, but are not limited to, work listed in parentheses. A more detailed listing of bid items can be found at: For Each Class of Work: An applicant who wishes to add a new class or classes of work in which they have not been previously prequalified must provide at least three references for each new work class. Reference instructions and forms can be found at: List all other states where applicant is currently qualified to perform work or has been qualified within the last three years. Class of Work States qualified within the last years (AB) Aggregate Bases (AC) Rock Production (Aggregate Crushing, Sanding Rock) (ACP) Asphalt Concrete Paving and Oiling (Paving, Chip Sealing, Crack Sealing, Slurry Sealing, Fog Sealing) (BLD1) Buildings (Toilets, Bathhouses, Maintenance, Sand Sheds) (EART) Earthwork and Drainage (Clearing, Earthwork, Blasting, Riprap, Culverts, Manholes, Inlets, Storm Sewers, Sanitary Systems) (ELEC) Electrical (Traffic Signals, Illumination, Ramp Meters, Roadway Weather Information Systems (RWIS), Variable Message Signs (VMS), Traffic Cameras) (LS) Landscaping (Roadside Seeding, Lawns, Shrubs, Trees, Irrigation Systems, Topsoil, Temporary and Permanent Erosion Control) (MHA) Miscellaneous Highway Appurtenances (Guardrail, Barrier, Curbs, Walks, Fences, Protective Screening, Impact Attenuators, Cold Plane Pavement Removal, Rumble Strips) (PAI1) Painting (Bridges and Buildings) (PAVE) Pavement Markings (Permanent - Painted, Durable, Markers, Delineators) (PCP) Portland Cement Concrete Paving (REIN) Bridges and Structures (Concrete, Steel, and Timber Bridges; Retaining Walls and Sound walls; Seismic Retrofit; Box Culverts; Structural Plate Pipe, and Pipe Arches) (SIGN) Signing (Permanent) (TTC) Temporary Traffic Control (All Temporary Traffic Control Items Including Flaggers and Pilot Cars) (OTH1) Other (List specific class) You may list "OTHER" (OTH1) classes of work; however, ODOT does not normally solicit bids under this class. This class of work is typically used by Local Agencies (Cities, Counties, etc.) ---PAGE BREAK--- Prime Contractor Prequalification Application Page 11 Revised June 2022 11 EXPERIENCE A. How many years has applicant been in business under present name? As a prime contractor? As a subcontractor? B. How many years' experience in construction work has applicant had? As a prime contractor? As a subcontractor? 12 EXPERIENCE – Continued What is the construction experience of all owners, officers, partners and principal individuals in applicant's organization? (Attach additional sheets, if needed) Individual's Name Present Position or Office Years of Construction Experience Magnitude and Type of Work 13 GENERAL REMARKS Use the following space for general remarks and explanations pertaining to the foregoing prequalification statements. Explain here any claimed experience of a business organization or entity other than the applicant or principals, including that of any business entity which was a predecessor of applicant or which has been acquired by applicant. ---PAGE BREAK--- Prime Contractor Prequalification Application Page 12 Revised June 2022 14 AFFIDAVIT STATE OF ) ss. County of ) I, being first sworn, state that I am of the applicant herein and that the statements made in (Title of individual authorized to execute bids and/or contracts) this application are true and I acknowledge that any false, deceptive or fraudulent statements on the application or at a hearing will result in the denial of prequalification, and may subject me to charges of false swearing or perjury; should there be any subsequent material reduction in applicant's ability to carry out any project for which applicant desires to submit a bid, applicant will give written notice of such change to the designated officer to whom this application is submitted at least ten days prior to the bid opening, and it is understood that such notice may change the eligibility of applicant to submit the bid. (Original Signature of Individual Authorized to Execute Bids and/or Contracts) Subscribed and sworn to before me this day of , Year Notary Seal or Stamp Original Notary Public Signature My commission expires