CS-4300NP (4-19) Mail To: NEW PRIME CONTRACTOR Bureau of … · 2019-04-22 · Part 1, Page 2...

Part 1, Page 1

CS-4300NP (4-19)

www.penndot.gov

NOTE: All requested information must be submitted in the format displayed on this form.The Department will not accept any substitute submission of the requestedinformation. This form must be completed in total.

Contractor __________________________________________________ __________________________________________________

Address 1 __________________________________________________Address 2 __________________________________________________

______________________________ _______ __________City State Zip Code

Telephone Number ______________ Fax Number ______________

Business Partner Registration Number _____________________________

Date Submitted __________

(Check One) New Application Renewal Application

FOR DEPARTMENT USE ONLY:

Financial StatementExamined/Accepted By: _______________________________________

Accountant

_________Date

Mail To:Bureau of Project DeliveryAttention: Prequalification Office400 North Street - 7th Floor NorthHarrisburg, PA 17120

A Corporation

__________________State of Incorporation

A Co-Partnership

An Individual

Affiliate/Subsidiary/Division

NEW PRIME CONTRACTORAPPLICATION

PART 1 - CONTRACTOR'S FINANCIAL STATEMENT

Part 1, Page 2

Directions and Guidelines Before Completion of the Part 1, “Contractor’s FinancialStatement” Form:

• Please use single-sided paper and do not bind Financial Information Packet.

• Financial Statements with negative working capital or working capital greater than $50,000must be audited.

• Reviewed statements will be accepted for financial statements with working capital less than$50,000.

• Compiled financial statements will not be accepted.

• Any financial statements submitted after six (6) months but less than nine (9) months from thebalance sheet date on your balance sheet will require a letter of assurance submitted and signed byyour Certified Public Accountant (CPA).

• Any financial statements submitted after nine (9) months from the balance sheet date on yourbalance sheet will not be accepted.

• Please make sure to attach your audited/reviewed financial statements to include at aminimum the independent auditors’ report, balance sheet, and notes/disclosures to thefinancial statements. The financial statements are to be in accordance with currentaccounting concepts published by the American Institute of Certified Public Accountants.The independent auditors’ report must have an opinion for the Part 1 section. “Unqualified”opinions need no further support.

• If the independent auditors/reviewed report has a ‘qualified’ opinion, then the contractor mustprovide documentation from their bonding company that the bonding company has the contractor’sfinancial records and will bond the contractor’s future work. Please see attached typical letters.

• The information submitted on the Contractor’s Financial Statement Form 4300, Part 1 should matchthe amounts found on the attached CPA audited or reviewed Balance Sheet.

• A consolidated balance sheet may be submitted with the Prequalification completed in the name ofthe parent. A consolidated balance sheet submitted with a Prequalification completed in the name ofthe subsidiary shall include a separate breakdown of the balance sheet or a ‘consolidating’ balancesheet that is included in the supplementary or additional information of the financial statementsubmission audited/reviewed by your CPA.

Part 1, Page 3

Instructions for the Completion of the Part 1, “Contractor’s Financial Statement”Form:

• The information submitted on the Contractor’s Financial Statement should match the amounts foundon the attached CPA audited or reviewed Balance Sheet.

• Contractor’s Financial Statement, Line 1, please list the total current assets from the balance sheet.

• Contractor’s Financial Statement, Line 2, please list the total current liabilities from the balancesheet.

• Contractor’s Financial Statement, Line 3, please subtract the total current liabilities from the totalcurrent assets on the balance sheet.

• Contractor’s Financial Statement, Line 4, please list the book value of the machinery and equipmentused in the course of business and include attached depreciation schedules. The book value ofequipment should include only machinery, equipment, and office equipment used in the course ofbusiness. Book values for Furniture, Fixtures, Land and Buildings should not be included.

• Contractor’s Financial Statement, Line 5, please list the approved maximum line of credit amount.

• Contractor’s Financial Statement, Line 6, please complete the expiration date for the line of credit.(Should match the date on the line of credit affidavit)

• Contractor’s Financial Statement, Line 7, please multiply the amount for the book value ofequipment (BE) listed on line 4 and the line of credit (LC) listed on line 5 by one half. Then addthose totals to the working capital (WC) determined on line 3. Multiple the total by your currentperformance factor (PF in formula), located on your current prequalification certificate, to determinethe potential maximum capacity. A new contractor’s performance factor will be a 6.

Part 1, Page 4

REVIEWED FINANCIAL STATEMENT

Section 457.4(b) of the Prequalification Regulations allows for the acceptance of a Reviewed FinancialStatement under certain conditions. In order to provide clarification as to how the Department intends toimplement this provision of the Prequalification Regulations, the following information is provided:

• A review statement will be accepted if the net working capital, as determined by the Comptroller’sOffice, is less than $50,000.

• A review statement will not be accepted if the net working capital, as determined by theComptroller’s Office, is negative.

• A review statement will not be accepted if the Maximum Capacity Rating (Q) as calculated in Section457.5(f) exceeds four million dollars ($4,000,000.00).

• If a Review Statement is not acceptable, you will be informed in writing by the Department that oneof the following options are available for consideration:

(a) A current audited financial statement may be submitted for the Department’sevaluation.

(b) Prequalification as a subcontractor may be requested as noted in Section 457.4(a)(5).Submission of Part 1, Financial Statement, is not required for subcontractor approval.

• An Accountant’s Certificate to accommodate a Review Statement has been inserted for your use, ifnecessary, following this sheet.

Part 1, Page 5

___________ Date

I (We) have reviewed the accompany balance sheet and related financial statement of

__________________________________________________________________ for the period ended

_____________, in accordance with standards established by the American Institute of Certified Public

Accountants. All information included in these financial statements is the representation of the

management of the company.

A review consists principally of inquiries of company personnel and analytical procedures applied

to financial data. It is substantially less in scope than an examination in accordance with generally

accepted auditing standards, the objective of which is the expression of an opinion regarding the

financial statements taken as a whole. Accordingly, we do not express such an opinion.

Based on our review, we are not aware of any material modifications that should be made to the

accompanying financial statements in order for them to be in conformity with generally accepted

accounting principles.

Registration Number ____________________ Signed _________________________________

___________________________________________________________________________________

Authorized to do business in ______________________________________________________

___________________________________________________________________________________

(May be substituted with certificate supplied from accountant)

Name of Certified Public Accountant/Public Accountant

Address

State

Accounting Firm Name

ACCOUNTANTS CERTIFICATE (Reviewed)

Part 1, Page 6

____________Date

I (We) have audited the balance sheet and related financial statements of

__________________________________________________________________________________

for the period ended ___________. These statements are the responsibility of the company’s

management. Our responsibility is to express an opinion on these statements based on our audits.

We conducted our audits in accordance with generally accepted auditing standards. Those

standards require that we plan and perform the audit to obtain reasonable assurance whether the

financial statements are free of material misstatement. Our audit included examining, on a test basis,

evidence supporting the amounts and disclosures in the financial statements. Our audit also included

assessing the accounting principles used and significant estimates made by management, as well as

evaluating the overall financial statement presentation. Any lines of credit extended by banks were also

verified. We believe that our audits provide a reasonable basis for our opinion.

In our opinion, the financial statements referred to above present fairly, in all material respects,

the financial position of _______________________________________________________________

as of _____________________, in conformity with generally accepted accounting principles.

Registration Number _____________________Signed _________________________________

___________________________________________________________________________________

Authorized to do business in ______________________________________________________

___________________________________________________________________________________

(May be substituted with certificate supplied from accountant)

Name of Certified Public Accountant/Public Accountant

Address

State

Accounting Firm Name

ACCOUNTANTS CERTIFICATE (Audited)

Part 1, Page 7

Contractor’s Financial Statement

Contractor __________________________________________________________________________ __________________________________________________________________________

Address 1 __________________________________________________Address 2 __________________________________________________ ______________________________ _______ __________

City State Zip Code

Business Partner Number: ___________________

1. Total Current Assets (CA) $_____________________

2. Total Current Liabilities (CL) $_____________________

3. Working Capital (WC) = (CA – CL) $_____________________

4. Book Value of Equipment (BVE) $_____________________

5. Line of Credit (LC) $_____________________

6. Line of Credit Expiration Date ______________

7. Potential Maximum Capacity Determined by PF * (WC + 1/2 BVE + 1/2 LC) = $_____________________ PF = Current Performance Factor (Found in current ECMS certificate) (New Contractors are assigned a PF of 6)

For Department Comptroller Use Only:

Application Date: ________________

Balance Sheet Date: _______________

Review/Audited: ________________

Prequalification Expiration Date: ______________

Reviewer: ____________________________

Date: ________________

Part 1, Page 8

TYPICAL BONDING LETTER

Date _________

Prequalification OfficerContract Management SectionBureau of Project DeliveryCommonwealth of PennsylvaniaDepartment of Transportation400 North StreetHarrisburg, PA 17120

Re: Contractor PrequalificationPart 1 Contractor Financial Statement

Dear Prequalification Officer:

It is our pleasure to review with you the bonding accommodations of Good Contractor, Inc., 123Main Street, Big Town, PA 12345.

Subject to our normal underwriting review, which includes reviewing the annual audited financialstatements, we will issue 100% performance and 100% payment bonds on contracts awarded to GoodContractor, Inc.

We have been extremely pleased by the positive feedback we have received from project ownersand have the utmost confidence in their company to perform any contract they wish to undertake in themost commendable manner.

If you should have any questions or need additional information, please let us know.

Sincerely,

Bonding Agency, Inc

Part 1, Page 9

TYPICAL BONDING LETTER

Mr. John DoeGood Contractor, Inc.123 Main StreetBig Town, PA 12345

Re: PennDOT Prequalification Substantiation

Dear John:

This is confirm for the benefit of any and all interested parties that X Surety is the bondingcompany for Good Contractor, Inc. and that we give the firm our highest recommendation.

In response to the prequalification request for the subject, please be advised that we would bewilling to provide performance and payment bonds for them on work for the Pennsylvania DOT.

Our willingness to extend surety is subject to the ongoing application of X Surety’s normalunderwriting standards including, but not limited to, review of the job specifications and details,acceptable contract terms, acceptable bond language, satisfactory evidence of adequate financing andthe principal’s financial condition and amount of work on hand at the time bonds are requested.

This letter is not a bid bond and does not create an obligation on the part of X Surety to provide asurety bond for any project unless and until Good Contractor, Inc. enters into a contract on terms thatmutually satisfy both Good Contractor, Inc. and X Surety at the time of bid or award as describe above.

We hold Good Contractor, Inc. in the highest regard and would give any request for suretysupport our fullest consideration.

Sincerely,

X Surety

Part 1, Page 10

LINE-OF-CREDIT STATEMENTS

Line-of-Credit Statements may be submitted from your banks for the purpose of establishing yourfinancial qualifications in determining your classification and rating. Such statements must, however, bespecific as to amount.

The next page, properly executed, is the official form, which must be used for a bank line-of-creditstatement. Any alterations will make the form null and void.

If more than one bank line-of-credit statement is being submitted the second or subsequent statementsmust be on the Pennsylvania Department of Transportation official form.

The name of the contractor being pre-qualified is the only name that is to be shown on the form.

CS-4300LOC (2-19)

LINE OF CREDIT STATEMENTwww.penndot.gov

Name of Bank _______________________________________ Street Address _______________________________________City/State/Zip _______________________________________

Date ___________

Mail To: Department of TransportationPrequalification Office400 North Street – 7th Floor NorthHarrisburg, Pennsylvania 17120-0094

BP ID ________________

A line of credit in the maximum amount of $_______________has been placed at the disposal of___________________________________________________________________________________for use when, as, and if needed throughout the one-year period beginning ______________, subject tothe usual conditions, including the requirement that the borrower’s financial condition and othercircumstances remain satisfactory to the bank at the time of any proposed borrowing. Should there beany reduction, termination, or increase in this line of credit, the Department of Transportation wouldappreciate being notified of these changes as soon as possible. The banking facility will not be heldaccountable in any fashion by the Department.

The following items, listed as liquid assets in Part 1 of the questionnaire being submitted by___________________________________________________________ have been pledged to securethe line of credit mentioned above:

*The line of credit mentioned has been given with full knowledge of accommodations extendedby other banks in amounts as follows: $ ________________

**It is not intended that this statement confer to the Department of Transportation or theCommonwealth of Pennsylvania any rights in and to said line of credit nor shall this statementcreate any obligation of ______________________________________________________________except as expressly set forth herein.

AFFIDAVIT

State of _______________________________________County of _____________________________________ SS: _______________________________________________________________________________________________ being dulysworn, deposes and says that they are ___________________________________________________of the ___________________________________________, the bank named in and which executedthe foregoing statement. Sworn to before me this ______ day of ________________, 20___.

___________________________________________________________(Bank Officer Sign Here)

___________________________________________________________(Notary Public)

(NOTARIAL SEAL)

(Name of Bank)

Part 1, Page 11

Part 1, Page 12

FOR A CORPORATION

COMPLETE THE FOLLOWING:

Corporate Name ____________________________________________________________________ ____________________________________________________________________Authorized Capital _____________________________Paid-in Capital ________________________________When Incorporated ___________________ In What State ________________________

Name and Address of Officers:

President __________________________________________________________________________Vice-President ______________________________________________________________________Secretary __________________________________________________________________________Treasurer __________________________________________________________________________

AFFIDAVIT FOR CORPORATION

STATE OF _____________________________________COUNTY OF ___________________________________ SS: _______________________________

The undersigned hereby declares: that the foregoing is a true statement of the financial condition of thecorporation herein first named, as of the date herein first given; that this statement is in response to aquestionnaire and that any depository, vendor or other agency herein named is hereby authorized tosupply such party with any information necessary to verify this statement.

_______________________________being duly sworn, deposes and says that they are__________________of the _________________________________________________________the

corporation described in and which executed the foregoing statement; that they are familiar with thebooks of the said corporation showing its financial condition; that the foregoing financial statement,taken from the books of the said corporation, is a true and accurate statement of the financial conditionas of the date thereof and that the answers to the foregoing interrogatories are true.

Sworn to before me this _____day of _______________,_____ (Year)

_____________________________________ __________________________________

(Title)

(Signature of Officer) Notary Public

CorporateSeal

(NOTARIAL SEAL)

Part 1, Page 13

FOR A CO-PARTNERSHIP


Firm Name _________________________________________________________________________Date of Organization _________________________________________________________________State whether Co-partnership is general or limited __________________________________________If limited, explain fully ____________________________________________________________________________________________________________________________________________________

Name and Address of Partners:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

AFFIDAVIT FOR CO-PARTNERSHIP


The undersigned hereby declares: that the foregoing is a true statement of the financial condition of theco-partnership herein first named, as of the date herein first given; that this statement is in response toa questionnaire and that any depository, vendor or other agency herein named is hereby authorized tosupply such party with any information necessary to verify this statement.

______________________ being duly sworn, deposes and says that they are a member of the firm of__________________________________________________________________________________;that they are familiar with the books of the said firm showing its financial condition; that the foregoingfinancial statement, taken from the books of the said firm, is a true and accurate statement of thefinancial condition of the said firm as of the date thereof and that the answers to the foregoinginterrogatories are true.

Sworn to before me this ____day of _______________, ______ (Year)

Signatures ______________________________ _____________________________________ ______________________________ ______________________________ ______________________________ ______________________________

(ALL PARTNERS OF FIRM MUST SIGN)

Notary Public

(NOTARIAL SEAL)

Part 1, Page 14

FOR AN INDIVIDUAL


Firm Name _________________________________________________________________________

AFFIDAVIT FOR INDIVIDUAL


The undersigned hereby declares: that the foregoing is a true statement of the financial condition of theindividual herein first named, as of the date herein first given; that this statement is in response to aquestionnaire and that any depository, vendor or other agency herein named is hereby authorized tosupply such party with any information necessary to verify this statement.

_______________________________ being duly sworn, deposes and says that the foregoing financialstatement, taken from their books, is a true and accurate statement of their financial condition as of thedate thereof and that the answers to the foregoing interrogatories are true.

Sworn to before me this ____ day of _____________, ____ (Year)

_____________________________________ ______________________________

(SIGNATURE OF INDIVIDUAL)Notary Public

(NOTARIAL SEAL)

Part 2, Page 1

CS-4300NP (4-19)

www.penndot.gov




Name of Company ____________________________________________________________________________________________________________________________________

Address 1 __________________________________________________Address 2 __________________________________________________ ______________________________ _______ __________

City State Zip Code

Telephone Number _______________ Fax Number _______________

Federal Identification No. ______________

Business Partner Registration No ____________________________________________(REQUIRED)

OUT-OF-STATE CONTRACTOR - Pennsylvania Resident AgentName of Company __________________________________________________________________

Address 1 __________________________________________________Address 2 __________________________________________________ ______________________________ _______ __________

City State Zip Code

NOTE: The Department reserves the right to request additional information for prequalification atany time as per the requirements of Title 67 Transportation, Section 457.17, Notification.

Form completed by (print): _______________________________________ Title: _______________________________________

PART 2 - ORGANIZATION AND EXPERIENCE STATEMENT

Part 2, Page 2

APPLICATION

The undersigned hereby applies for qualification to perform the following types of work, as described inthe Pennsylvania Department of Transportation Specifications, Publication 408M (408).

WORK CLASSIFICATION (CHECK THOSE DESIRED)WORK WORK CLASSIFICATION

EARTHWORK

BASE COURSE

PAVEMENT

INCIDENTALCONSTRUCTION

ROADSIDE

ABCC1

C2C5C6C4DEFF1F2F3F4GG1G2G3G4WB1C3HH1H2JJ1J2J3KK1K2LMM1M2M3NN1

Clearing and GrubbingBuilding DemolitionNew Roadway Excavating and GradingOther Excavation and Grading (Roadway Patches, StructureRelated, Drainage, etc.)Drilling and BlastingAnchorsDrillingRubblizingRigid Base CourseFlexible Base CourseBituminous PavementBituminous Pavement Patching and RepairBituminous Joint and Crack SealingMilling, Rumble Strips, Scarification Bituminous or ConcreteBituminous Surface Treatments, Seal CoatsRigid PavementRigid Pavement Patching and RepairDiamond, Carbide Grinding Concrete or BituminousSpall RepairJoint Rehabilitation, Sawing and Sealing Concrete or BituminousRailroad ConstructionAsbestos RemovalGeotextilesDrainage, Water Main, Storm SewerPipe and Culvert CleaningPavement Base DrainsGuide Rail, Steel Median Barrier, FencesConcrete Median BarrierFencing, RailingsImpact Attenuating DevicesCurbs, Sidewalks, Inlets, ManholesMasonry WorkConcrete and Masonry CoatingsSlabjacking, SubsealingLandscapingSelective Tree Removal, TrimmingSilt Barrier Fence, Gabions, Erosion ControlSeeding and Soil SupplementsBuilding Construction and Related TradesRelated Building Trades

3

Part 2, Page 3

TRAFFICACCOMMODATIONS& CONTROL

STRUCTURES(Bridges)

OO1O2O3PP1P2P3P4P5P6P7P8QRR1SS1

S2S3S4S5S6S7S8S9S0TT1T3T4T5T6T7T8T9UU1VV1V2

Pavement MarkingsRaised, Recessed Pavement MarkersPlastic ApplicationsPaint ApplicationsHighway/Sign Lighting, Traffic Signal ControlCCTV, RWIS, Automated Anti Deicing SystemsHighway Advisory Radio System (HAR)Dynamic Message Signs (DMS)Integrated Communications SystemsLevel 1 System Integrators (Hardware)Level 2 System Integrators (Software)Level 3 System Integrators (Hardware/Software)Highway/Sign Lighting, ElectricalMaintenance and Protection of TrafficSign Placement (Post/Structure Mounted)Sign Structures (Refer to Pub. 408, Section 948)Cement Concrete Bridges Over 120 ft.Cement Concrete Bridges up to 120 ft. and Steel Bridges withStraight Girders up to 120 ft.Repair and Rehabilitation of Structures Concrete or SteelModified Concrete Deck OverlaysBridge Culverts, Pedestrian Bridges, Timber BridgesStructural WallsErection of Prestressed Concrete BeamsRebar InstallationTransportation TunnelsBridge Deck Placement or RepairMarine WorkAll Steel Bridges with Curved Girders or over 120 ft.Bridge RemovalErection of Fabricated Steel MembersWeldingBearing Pads and SealsExpansion DamsBridge DrainageShear Studs, Metal Bridge Deck FormsParapetsPile DrivingCaissons ( Refer to Pub. 408, Section 1006.3 (k) )Field Steel Surface Preparation and PaintingShop Steel PaintingDisposal of Bridge Waste/Containment/Worker Health and Safety

List the states in which you are prequalified for highway construction work and applicable maximumcapacity rating: STATE AMOUNT OF MAXIMUM CAPACITY RATING________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________

Part 2, Page 4

The following questions also pertain to affiliates and subsidiaries

1. How many years has your organization been in business as a contractor under your presentbusiness name? ________________________________________________________________

2. How many years of experience in highway construction work has your organization had?____________

3. List the construction experience of the officers and management personnel includingsuperintendents of your organization.

4. Has your company ever failed to complete any work awarded to you? _____________________If so, give dates, projects and reasons therefore____________________________________________________________________________________________________________________________________________________________

5. Has any officer or partner of your organization ever been an officer or partner of some otherorganization that failed to complete a construction contract? _____________________________ If so, state name of individual, other organization, dates, project, and reason therefore____________________________________________________________________________________________________________________________________________________________

6. Has any officer or partner of your organization ever failed to complete a construction contracthandled in their own name? ______________________________________________________If so, state name of individual, name of owner and reason therefore ____________________________________________________________________________________________________________________________________________________________

7. Has your organization or an officer of your organization ever been denied prequalification in thisstate or any other state under this name or any other name? _____________________________ If so, please indicate state(s), and explain reasons for denial __________________________________________________________________________________________________________________________________________________

INDIVIDUAL’SNAME

PRESENTPOSITIONOR TITLE

YEARS OFCONSTRUCTIONEXPERIENCE

TYPE OFCONSTRUCTION

WORKIN WHATPOSITION

Part 2, Page 5


8. Has your organization or an officer of your organization ever been disqualified or removed from abidding list in this State or any other state, or from a Federal Government bidding list under thisname or any other name?_________________________________________________________If so, please indicate state(s) and/or Federal agency and explain reasons for denial. ____________________________________________________________________________________________________________________________________________________________

9. List all affiliated or subsidiary organizations and companies. ____________________________________________________________________________________________________________________________________________________________Please complete information on Part 2, Page 6 if you are requesting prequalification approval forsubsidiary organizations and/or companies.

10. List all organizations and individuals that have a financial interest of ten percent (10%) or more inyour company.__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

11. List all persons having a financial interest in this organization and who also have a financialinterest in another organization prequalified or eligible to bid in this state or any other state. ____________________________________________________________________________________________________________________________________________________________

12. List any other organization or individual who controls or influences the bidding of this organization. ____________________________________________________________________________________________________________________________________________________________

Part 2, Page 6


REQUEST FOR SUBSIDIARY PREQUALIFICATION

1) Name ________________________________________________________________________

Address 1 __________________________________________________Address 2 __________________________________________________ ______________________________ _______ __________

City State Zip Code Telephone ________________

Fax Number ________________

Federal Identification No. _______________

List of Officers, Management Personnel, and Superintendents:

Individual Name Position or Title

__________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________

(Make additional copies if needed)

Part 2, Page 7

13. List contracts which will show the various types of work completed by your organization in the past5 years. Complete below with filling out the following pages or attach your own spreadsheet.

NAME AND ADDRESS OF OWNER**Address must be adequate to assure replyto inquiry and verification. Failure to receivereply will delay processing of application.

NAME AND LOCATION OF PROJECTGIVE DETAIL DESCRIPTION OFWORK PERFORMED

(Include e.g. quantities, lengths, miles,sizes, types, etc.)

NAME AND ADDRESS OF PRIMECONTRACTORIf you were a subcontractor

CONTRACT AMOUNT (If subcontractor, indicate subcontracted amount)Was contract completed on time? If “NO” explain why under Number 15. YES NO

Were there any penalties imposed? If “YES” give amount and explain under Number 15. YES NOWere there any liens, claims, or stopnotices filed against job? If “YES” explain under Number 15. YES NO







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Part 2, Page 8

14. PLANT AND EQUIPMENTList equipment owned. Also list and indicate separately, equipment under lease or otherwiseavailable to you, with attached explanation of the arrangements. The list of equipment should beidentical with those shown in your Financial Statement, and must be shown below to be creditedwith the technical evaluation of your application. Complete below or attach your own report.

QUANTITY ITEM SIZE ORCAPACITYCONDITION

(Poor, Fair, Good,or Excellent)

YEARSOF

SERVICE

Part 2, Page 9

15. Explanation of details in connection with non-completion of contracts; penalties imposed; liens,claims and stop notices filed against contracts listed under No. 13. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

16. Complete statement of misdemeanor convictions involving moral turpitude, convictions of biddingrelated crimes, and all felony convictions of the contractor, as well as the contractor’s directors,principal officers and key employees. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

17. Give any further or relevant, pertinent and material facts that will justify approval of the requestedwork classifications.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

18. If you are a parent organization and desire to do business in Pennsylvania through branch offices,indicate below the official name and address of each branch. Also indicate a mailing address ifdifferent than the address listed on the Cover Sheet, Page 1.NAME ADDRESS___________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ __________________________________________________

19. Act 89 of 2013 amended the State Highway Law to require certification for contractors who performsurface preparation and industrial coating application on steel structures in the field and forcontractors who perform industrial hazardous paint removal in a field operation. Currently, thesetypes of certifications are limited to the Society for Protective Coatings (SSPC) QP1 and QP2Certifications. Please indicate the declaration that best describes your organization’s status:

My organization is QP1 Certified and evidence of the validity of this Certification is attached. My organization is QP1 and QP2 Certified and evidence of the validity of these Certifications is attached.My organization self-performs this type of work but is not QP1 Certified.My organization does not self-perform this type of work.

Part 2, Page 10

NOTARY PAGE

Date at ______________________________________________ this ______

day of, __________________, ______ (year).

__________________________________________________________________________________(NAME OF ORGANIZATION)

__________________________________________________________________________________(SIGNATURE AND TITLE OF PERSON SIGNING)

COUNTY OF ________________________________________

SS: ______________________________

COMMONWEALTH / STATE OF _______________________

__________________________________________ being duly sworn, deposes and says that they are (PRINT NAME)

_________________________________ of(TITLE)


and that the answers to the foregoing questions and all statements therein contained are true and correct.

Sworn to before me this

_____________ day of _____________, _______ (year)

_____________________________________________(NOTARY SEAL) (NOTARY PUBLIC)

_____________________MY COMMISSION EXPIRES

Part 3, Page 1

CS-4300NP (4-19)

www.penndot.gov




Name of Company: ____________________________________________________________________________________________________________________________________

Equal Employment Policy Officer: _______________________________________________________

Date Submitted: _____________

Business Partner Registration No.: ______________________________________________________

___________________________________________________________________________________

Act 89 of 2013 amended Section 303 of Title 74 of the Pennsylvania Consolidated Statutes to ensurethat contracting entities maximize the participation of Diverse Businesses (DBs). All contractors that arecertified as Disadvantaged Business Enterprises (DBEs) by the Pennsylvania Unified CertificationProgram (PA UCP) are also recognized as DBs. Other DBs include minority-owned businesses,women-owned businesses, veteran-owned small businesses, and service-disabled veteran-owned smallbusinesses; but these DBs must be certified by an appropriate third-party certifying organization.

If your firm is recognized as a DB then check the following:

My organization is certified by one of the following, as recognized under Act 89 of Commonwealth ofPennsylvania:

• The National Minority Supplier Development Council

• The Women’s Business Development Enterprise National Council

• The Small Business Administration

• The Department of Veterans Affairs

• The Pennsylvania Unified Certification Program (PA UCP)

(Please attach proof of certification unless certified by PA UCP)

This section for PennDOT use only:

Accepted by: _______________________________ _______________(Signature/Title) (Date)

PART 3 - AFFIRMATIVE ACTION STATEMENT

Part 3, Page 2

Pursuant to the provisions of Executive Order 1996-8; Nondiscrimination Clauses; Pennsylvania HumanRelations Act; Pennsylvania Department of Transportation, Chapter 457 Regulations (Prequalification);Civil Rights Act of 1964, as amended; Executive Order 11246, as amended; 23, USC, Sec 22 ofFederal-aid Highway Act of 1968; and other related laws:

1. It is the policy of the ____________________________________________________________to ensure that applicants are employed and that employees are treated, during employment,without regard to their race, religion, gender, age, color, national origin and/or disability. Suchaction shall include: employment upgrading, demotion, or transfer; recruitment or recruitmentadvertising; layoff or termination; rates of pay or other forms of compensation; and selection fortraining, including apprenticeship, pre-apprenticeship, and/or on-the-job training.

2. __________________________________ is the name of Contractor’s Equal Employment PolicyOfficer.

3. It is hereby agreed, as part of this prequalification, that the following steps be taken to ensureequal opportunity in employment:

a. Require that all advertisements for personnel contain the notation “An Equal OpportunityEmployer M/W” (Minority/Women) and that all advertisements be inserted in newspapershaving a large general circulation in the area and among minority groups.

b. Utilize, direct and systematically recruit personnel through all public and private employeereferral sources likely to yield qualified minority groups and women applicants, including butnot limited to schools, colleges, minority groups, and women organizations. Establish andmaintain a current list of minority and women recruitment sources, provide written notificationto these recruitment sources and community organizations when the contractor or its unionshave employment opportunities available; follow-up and maintain documentation of theorganizations’ responses.

c. Encourage current employees to refer minorities and women for employment.

4. Additionally, as part of this prequalification, it is further hereby agreed, that in order to ensurenondiscriminatory hiring, that the following steps have been taken:

a. All members of contractor’s staff who are authorized to hire, supervise, promote, anddischarge employees, or who recommend such action, or who are substantially involved insuch action, will be made fully cognizant of, and will implement the company’s EqualEmployment Opportunity Policy and the Policy of the Department.

b. All work supervisors, personnel officers, company officers and other employees have beenadvised of our Equal Employment Opportunity Policy.

c. All labor unions and other recruitment sources will post a notice to be provided by thecontracting agency setting forth the provisions of the Nondiscrimination Clause. The noticeshall be posted in a conspicuous place that is accessible to employees, agents, applicantsfor employment, and other persons.

Part 3, Page 3

d. Good faith efforts will be utilized with unions to develop programs to ensure qualifiedminorities and women have equal opportunity for employment and training.

e. It is further agreed that good faith efforts will be utilized in conjunction with the labor unions,to obtain qualified minority and woman representation in all classifications on the job and inall phases of the work.

f. The unions which represent our work force are: (If you are non-union, please indicate):

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

and it has been their policy to accept for membership, qualified personnel without regard torace, religion, color, sex, age or ethnic origin.

5. As part of this prequalification, we will make use of apprenticeship and/or other training programsin one or more of the following ways:

a. Continually assisting minorities and women to enter pre-apprenticeship and apprenticeship training programs,

b. Actively engage in efforts to increase the skills of minorities and women so that they mayqualify for higher paying employment (upgrading),

c. Regularly participating in programs, such as union apprenticeships, that ensure equitableconsideration of all applicants. Such as programs having been approved by the Bureau ofApprenticeship and Training of the United States Department of Labor, and/or thePennsylvania Apprenticeship and Training Council.

d. We presently have apprenticeship or on-the-job training programs for the following skillsand/or crafts: (If none, please state.)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6. Where the practices of a union, any training program or other source of recruitment will result inthe exclusion of minorities and women, which prevents the contractor from being able to meet itsobligation under the Contract Compliance Regulations issued by the Governor’s Office ofAdministration, the United States Department of Labor, or this nondiscrimination clause, thecontractor shall fill vacancies through other nondiscriminatory employment procedures.

7. Are you currently a recipient of contracts with the Commonwealth of PA in addition to PennDOT?If yes, please indicate agency (ies).

YES NO_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________

8. Has any federal or state agency conducted an EEO compliance review of your firm within thepast two years? If yes, please indicate agency (ies) and date(s).

YES NO__________________________________________________________________________________________________________________________________________________________

9. Has a Title VI and/or EEO complaint been filed against your firm?

YES NO

10. Is your firm currently under a conciliation agreement or corrective action plan for non-compliancewith applicable Federal requirements?

YES NO

11. Does the contractor have a written Equal Opportunity Plan?

YES NO

12. It is also agreed that:

a. When bids are being solicited, the contractor shall actively solicit bids from minority-disadvantaged and/or woman subcontractors.

b. Officials will conduct systematic reviews in order to ensure that the company’s EEO programis implemented.

c. We shall physically include the provisions of the nondiscrimination clause(s) and all otherapplicable EEO Clauses in every subcontract, [i.e., FHWA 1273, Required ContractProvisions Federal-Aid Construction Contracts, (Revised May 1, 2012); Executive Order11246, as Amended (Notice of Requirement For Affirmative Action To Ensure EqualEmployment Opportunity); Item 1999-9999, Trainees Special Provisions Federal/State (AsApplicable)]. All other Designated Special Provisions (DSPs) shall be included by referenceso that such provisions will be binding upon each subcontractor.

d. We will submit any required training program (if applicable), in accordance with establishedDepartment procedures and Items 1999-9999 or 1999-0000 Trainees/Special TrainingProvisions. Required Training Program, EO-363 will be submitted 10 days following theNotice to Proceed.

Part 3, Page 4

Part 3, Page 5

1) Submit an Initial Report (EO-364) for each trainee prior to filling any training position(s).

2) Submit monthly Training Reports (EO-365) in a timely manner.

13. We will furnish all information and reports required by Federal and State Rules and Regulations,as well as permit access to contractor’s employees, books, records and accounts by thePennsylvania Department of Transportation and the Governor’s Office of Administration, forpurposes of investigation to ascertain compliance.

14. We agree to notify all subcontractors, unions, vendors or suppliers of their responsibilities tocomply with state and/or federal regulations.

15. We agree to send to each subcontractor, union, and supplier of employees or materials thenondiscrimination clause.

16. We agree not to use subcontractors, vendors or suppliers on State contracts who are reported tobe in noncompliance or un-awardable by a State agency Contract Compliance Officer.

Part 3, Page 6

NOTARY PAGE

Date at ______________________________________________ this ______

day of, __________________, ______ (year).


__________________________________________________________________________________(SIGNATURE AND TITLE OF PERSON SIGNING)

COUNTY OF ________________________________________

SS: ______________________________

COMMONWEALTH / STATE OF _______________________

__________________________________________ being duly sworn, deposes and says that they are (PRINT NAME)

_________________________________ of(TITLE)


and that the answers to the foregoing questions and all statements therein contained are true and correct.

Sworn to before me this

_____________ day of _____________, _______ (year)

_____________________________________________(NOTARY SEAL) (NOTARY PUBLIC)

_____________________MY COMMISSION EXPIRES

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