ࡱ> KMJ jbjb77 ".]]G<e  ooo8D>2"===k$k$k$%>'>'>'>'>'>'>?VB'>ok$K" k$k$o$'>G%==<>G%G%G%s$:=o=%>G%k$%>G%G%;qo=%(]W$q<>$R>0><\BG%B0=G%o=k$k$k$  :   Contractors Qualification Statement The undersigned certifies under oath that the information provided herein is true and sufficiently complete so as not to be misleading.   Submitted To: Submitted By: Mailing Address: Phone Number: Email Address:  Principal Office:  Name of Project: Type of Work: Architecture: Engineering:  Environmental: Other: Organization: How many years has your organization been in business? - How many years has your organization been in business with its present name?  Under what other business name has your organization worked as? If your organization is a corporation? Answer the following: Date of Corporation: State of Incorporation: Tax Identification #: President Name: Vice President Name: Treasurer Name: Secretary Name: If your organization is a partnership, answer the following questions: Date of Organization: Type of Partnership: Name(s) of general partner(s): If your organization is individually owned, answer the following questions: Date of Organization Name of Owner: - If your organization is other that what is listed above, please describe it and name the principals: Licensing & Insurance: List jurisdictions and trade categories in which your organization is legally qualified to do business and indicate registration and license numbers, if applicable:   - List general liability insurance and workers compensation insurers name, policy number, and expiration dates: Experience: List the categories of work that your organization normally performs with its own forces.  3.2 Claims & Suits: (If any answer below is yes, please attach details) Has your organization ever failed to completed work it has been awarded? Are there any judgments, claims, arbitration proceedings or suits pending or outstanding against your organization or its officers? Has your organization filed any claims, lawsuits or requested arbitration with regards to construction contracts within the last five years? 3.3 Within the last five years, has any officer or principal of your organization ever been an officer or a principal of another organization when it failed to complete a construction contract? 3.4 On a separate sheet, please list major projects your organization has in progress, giving the name of the project, architect, contractual amount and date of completion State total worth of work in progress under a contract agreement. 3.5 On a separate sheet, list the major projects your organization has completed in the past five years, giving project name, builder, contractual amount and date of completion. State the average annual amount of work performed over the past five years. References: 4.1 - Trade References:  4.2 Bank References:  Financing: 5.1 Financial Statement:  Signature of Approval: - Dated at - List name of organization: List any further information regarding your organization in the box below. _____________________ being duly sworn deposes and says that the information provided herein is true and sufficiently complete as to not be misleading ________________________, of ________________________ personally appeared before me, the undersigned notary public, and provided satisfactory identification to be the person who signed this document in my presence and swore or affirmed that the contents of this document are true and accurate to his/her knowledge.  Notarized Date: Subscribed and sworn before this ______ day of __________ Notary Public: My Commission Expires: Signature:_______________________________________ FORM A - TECHNICAL QUALIFICATIONS PAGE  PAGE 4 Date: Island Housing Trust POB 779 West Tisbury, MA 02575 X %     . 0 B g k m v ) * s t } ~ [\sjhPcCJUmHnHuhPc5CJ\hE(hPc5CJ\jhPcUmHnHuhPc$jhPc5CJU\mHnHuhE(5CJ\jhohiCJUmHnHuhohihEh9ZhqjhE(CJUmHnHuhE( hE(CJ,)%&'    - . k dh$a$ &d P  ) l m n o   / A ' < K  & Fdh & Fdh & Fdhdh^dh & Fdh & Fdh s u v w x y z { | } []^_`abc & FgdPc^gdPcgdPc & FgdPc & Fcz|t & F^ & F & F{|st/02Mtuwxjkqrsuv|}~𲬲𲬲 h6hPchPc0JmHnHu hPc0JjhPc0JUhPc5>*B* \ph3fjhPcUmHnHujhPcCJUmHnHuhPc5CJ\hPchPc5B* \ph3f</12Muvw`ab hh^h`hgdPch^hhdh^h^ & Fdh & FdhGijstugdPch]h&`#$hdh^hgdPchdh^hgdPc h6hPchPc 1h/ =!"#$%666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH RR  Heading 1$dh@&^5B* \ph3fDD  Heading 2$@&5B* \ph3fRR  Heading 3$dh@&^5B* \ph3fDA`D Default Paragraph FontZiZ  Table Normal :V 4 l4a _H(k (No List 6>@6 Title$a$ 5CJ(\BJB Subtitle$a$6B*]ph3f>B@> Body Text5B* \ph3f4 @"4 Footer  !.)@1. 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