PART 1: CORPORATE PROFILE INFORMATION
COMPANY NAME & HEADQUARTERS ADDRESS : (Responsible For Submitting Invoices And Receiving Payments)
FEDERAL IDENTIFICATION NUMBER:
PRIMARY CONTACT NAME RESPONSIBLE FOR RECEIVING PROJECT REQUESTS (Project Definitions or Requests for Training, etc):
PRIMARY
CONTACT TELEPHONE:
( )
CONTACT NAME:
____ Mr. ____ Ms. (check one)
PRIMARY
CONTACT FAX NUMBER:
( )
ADDRESS:
COUNTY: PRIMARY
CONTACT E-MAIL ADDRESS:
COUNTY:
TYPE OF FIRM (Check one only)
___CORPORATION ___PARTNERSHIP ___PROPRIETORSHIP ____ JOINT VENTURE
___LLC ___LLP ___OTHER (Describe)
MANAGEMENT PROFILE (Identify each person who is, or has been within the past five years, an owner of 5% or more of the firm’s shares, a director, an officer, a partner or proprietor. Joint ventures: provide information for all firms involved. Fill in name, % owned, office held (title), indicate by Y or N whether director, officer or partner.)
FULL TITLE % DIRECTOR OFFICER PARTNER
NAME OWNED
1.______________________ _____________ _____ _____ _____ _____
2.______________________ _____________ _____ _____ _____ _____
3.______________________ _____________ _____ _____ _____ _____
4.______________________ _____________ _____ _____ _____ _____
(add additional sheets if necessary)
BIDDER QUALIFICATION FILING
PART 2: MANDATORY DISCLOSURES
The following section must be fully completed by Bidder or Bidder will be deemed non-responsive. Where appropriate, provide additional details using space provided or by inserting additional sheets following this part.
1a. Are you a New York State resident business?
[A resident business is one who maintains a corporate headquarters within NYS, & offers goods &/or services which are substantially produced, assembled, or performed within NYS]
1b. If not a resident NYS business, you must be registered within your respective State's Department of State (DOS) or equivalent government entity in order for a contract award to be approved.
_______ NO _______ YES
2. How many years has your firm been in business? ________ Years
3a. Is your firm at least 51% owned and controlled by minority group members?
(e.g. Black Hispanic, Asian, Pacific Islander American Indian, Alaskan Native)?
3b. Is your firm at least 51% owned by women?
4. How many people are employed by your firm? ________ Employees
5. Breakdown by location of people employed by your firm (total should equal item #4 above):
Within New York?
Outside of New York & within U.S.?
Outside of U.S.?
___________
___________
___________
6a. Is your company independently owned and operated?
b) Does your firm have significant control of the market space?
_______ NO _______ YES (If no, provide details)
_______ NO _______ YES 7. List and describe any liquidated damages assessed, and/or liens or claims over $25,000
filed against the firm and remaining undischarged or unsatisfied for more than 90 days, on any contracts within the past five years.
Check one:
______ List attached ______ Not Applicable 8. Within the past five years has the firm, any affiliate, any predecessor company or entity,
owner of 5.0% or more of the firm’s shares, director, officer, partner or proprietor been the subject of:
a) a judgment of conviction for any business-related conduct constituting a crime under state or federal law?
b) a currently pending indictment for any business-related conduct constituting a crime under state or federal law?
c) a grant of immunity for any business-related conduct constituting a crime under a state or federal law?
d) a federal suspension or debarment, New York rejection of any bid or disapproval of any proposed subcontract for lack of responsibility, denial or revocation of qualification in any state, or a voluntary exclusion agreement?
Check any that apply. If “yes”, describe using additional pages if necessary)
______ NO _______ YES
______ NO _______ YES
______ NO _______ YES
______ NO _______ YES
PART 2: MANDATORY DISCLOSURES - cont'd
e) any federal determination of a violation of any labor law or regulation, or any OSHA “serious violation”?
was violation willful?
f) any state determination of a violation of any labor law or regulation?
g) any state determination of a Public work violation?
was violation deemed willful?
(Check any that apply. If “yes”, describe using additional pages if necessary) h) has there been a revocation of, MBE or WBE certification?
i) was there a rejection of a low bid on a state contract for failure to meet statutory affirmative action or MWBE requirements?
j) Has there been a consent order with the NYS Department of Environmental Conservation, or a federal or state enforcement determination involving a construction-related violation of federal or state environmental laws? (If not applicable, respond with N/A.)
k) Has there been a finding of non-responsibility by an agency or authority due to the intentional provision of false or incomplete information required by Executive Order 127?
Executive Order 127 requirements can be found at:
http://www.ogs.state.ny.us/legal/ExeOrder127/overview.asp
9. Does this company retain partnership or reciprocal agreements with hardware and/or software companies, or with associated manufacturers in this industry?
______ NO _______ YES (If yes, provide details.)
10. List by agency or department all current contracts your firm holds with the State of New York, its departments or political subdivisions:
(If not applicable, respond with N/A.)
Check one:
______ List attached ______ Not Applicable
11. List by name all current contracts which your firm holds with major governmental entities outside of New York State:
Check one:
______ List attached ______ Not Applicable
12. Do any of your employees as of the time of this filing, also work as a direct employee
for any Authorized User of the PSG IT Services contracts? _______ NO _______ YES (If yes, provide details) 13. Your firm is responsible for providing worker’s compensation insurance pursuant to
state law. The State has the option to require proof of current worker’s compensation
insurance or proof of exemption if applicable. Do you understand this requirement? _______ NO _______ YES 14. Your firm is responsible for providing disability insurance pursuant to state law. The
State has the option to require proof of current worker’s compensation insurance or
proof of exemption if applicable. Do you understand this requirement? _______ NO _______ YES 15a. Does your firm employ any non-U.S. citizens or resident legal aliens?
15b. If yes, are the forms on file and available for inspection?
_______ NO _______ YES _______ NO _______ YES 16. Current legislation authorizes the New York State Education Department (SED) to
license/register non-degree granting computer training facilities in New York State.
If you are a private school or a registered business school/computer training facility in New York State, it is your responsibility to contact the SED, Bureau of Proprietary School Supervision, to become informed about the applicability of Article 101 of the Education Law. For additional information telephone: (518) 474-3969; fax: (518)
This is for your information only - no response required
17. NONDISCRIMINATION IN EMPLOYMENT IN NORTHERN IRELAND:
MACBRIDE FAIR EMPLOYMENT PRINCIPLES:
In accordance with Section 165 of the State Finance Law, the bidder, by submission of this bid, certifies that it or any individual or legal entity in which the bidder holds a 10% or greater ownership interest, or any individual or legal entity that holds a 10% or greater ownership interest in the bidder, either:
Answer YES or NO to one or both of the following, as applicable, A. have business operations in Northern Ireland:
If YES,
B. shall take lawful steps in good faith to conduct any business operations in Northern Ireland in accordance with the MacBride Fair Employment Principles relating to non-discrimination in employment and freedom of workplace opportunity regarding such operations in Northern Ireland, and shall permit independent monitoring of compliance with such Principles.
_______ NO _______ YES
_______ NO _______ YES
18. BIDDER/OFFERER DISCLOSURE OF PRIOR NON-RESPONSIBILITY DETERMINATIONS - Pursuant to Procurement Lobbying Law (SFL §139-j):
A. Has any Governmental Entity made a finding of non-responsibility regarding the individual or entity seeking to enter into the Procurement Contract in the previous four
years? _______ NO _______ YES
If yes, please answer the following question:
B. Was the basis for the finding of non-responsibility due to a violation of State Finance
Law §139-j? _______ NO _______ YES
C. If yes, was the basis for the finding of non-responsibility due to the intentional
provision of false or incomplete information to a governmental entity? _______ NO _______ YES If yes, please provide details regarding the finding of non-responsibility:
_______
D. Has any governmental agency terminated or withheld a procurement contract with the above-named individual or entity due to the intentional provision of false or incomplete information?
Date of Termination or Withholding of Contract:
Basis of Termination or Withholding:
(add additional pages if necessary)
END OF PROCUREMENT LOBBYING QUESTIONS
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_______
_______ _______
_______ _______
BIDDER QUALIFICATION FILING