NOTICE!!

THIS IS AN OFFICIAL DOCUMENT THAT IS USED TO DETERMINE THE

QUALIFICATIONS OF CONTRACTORS TO BID WITH THE AGENCY OF
TRANSPORTATION FOR THE STATE OF VERMONT. ANY ALTERATIONS OF THIS
DOCUMENT WILL MAKE YOUR QUESTIONNAIRE INVALID AND IT WILL NOT BE
ACCEPTED BY THIS OFFICE.

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 STATE OF VERMONT
AGENCY OF TRANSPORTATION

CONTRACTORS
EXPERIENCE QUESTIONNAIRE
AND FINANCIAL STATEMENT
Submitted by: _________________________________ _______________________________________
(Name) (Title)

Business: ____________________________________________________________________________

Mailing Address: ______________________________________________________________________

(Street or Box No.) (City) (State) (Zip Code)
Location Address: _____________________________________________________________________

Telephone Number: ______________________________ Federal ID Number: ________________

(Area Code) (No.)

Facsimile Number: ______________________________ Email Address: ____________________

(Area Code) (No.)
Financial Statement
as of: ____________________ 20___ Submitted: _______________ 20___
Date Received: _____________________

Date Checked: _____________________

PLEASE NOTE: DO NOT BIND OR HOLE PUNCH THIS DOCUMENT IN ANYWAY.

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STATE OF VERMONT AGENCY OF TRANSPORTATION
INSTRUCTIONS FOR FILING THE QUESTIONNAIRE, FINANCIAL STATEMENT AND
OTHER GENERAL INFORMATION FOR CONTRACTORS
1. Preparation of Statement.

One (1) copy of the questionnaire is required by the Agency. It must be completely executed and properly sworn to before a Notary Public. The contractor’s allowable Maximum
Capacity Rating is dependent on the type of financial information submitted and is subject to adjustment factor as indicated in the following chart:

Type of Financial Information Submitted Adjustment Factor Allowable Range of Maximum Capacity Rating

In-House Non-CPA or Compiled Financial 0.70 0 -$2,000,000

Information
Reviewed Financial Statement 0.85 0 - $4,000,000
Fully Audited Financial Statement None 0 – Unlimited

Financial statements which are compiled, reviewed, or fully audited must be prepared and certified by an Independent Certified Public Accountant (CPA). A “Certified Public
Accountant” is considered one who, in Vermont, is registered by the State of Vermont Board of Public Accountancy as a CPA. For other states the Agency will consider a CPA
whose registration qualifications in their state equal those established in Vermont. This questionnaire must be submitted at least ten (10) working days before the bid opening date
in order to ensure consideration for prequalification for a particular bid opening.

2. Notification of Action Taken.

The Agency will send in writing to the applicant a notification of its decision. Questionnaires will be considered in the order received and acted upon as promptly as circumstances
permit. Contractors duly prequalified will be apprised in writing of both the amount and type of work on which they will be eligible to bid, and as to the number of projects which
they may have under contract at any time.

3. Duration of Prequalification.

Annual Prequalification expires one (1) year from the date of the end of the contractor's fiscal year included in the financial statement provided to the Committee. Contractors will
be notified in writing of the date their respective renewal periods begin. A contractor shall automatically have four (4) months from the end of its fiscal year to renew its Annual
Prequalification. No extension of time beyond the four (4) months will be given to any entity.

4. Submission of a New Questionnaire for Renewal of Prequalification.

A prequalified contractor must submit a new questionnaire on a yearly basis for review by the Prequalification Committee in order to maintain a continuous prequalification rating.
The date of filing must be at least ten (10) working days prior to the end of the renewal period .

5. Revision of Prequalification Rating.

Except as otherwise provided, requests for revision of a rating(s) or work classification will be considered at any time provided information is submitted showing changed assets,
equipment, supervisory personnel, and/or ability to perform work. Timely filing of a rating and/or work classification revision request does not guarantee that a contractor will be
allowed to bid on a specific contract, or even that the request will be considered by the Committee prior to a specific bid opening. Therefore, the Agency urges that any request for
such revisions be filed as soon as possible, but no later than ten (10) working days in advance of the bid opening for which the revision is requested. The ten (10) working day
minimum period will be adequate only when no additional information is required and the contractor does not appeal the Committee’s decision(s). Requests for revision of
prequalification rating will be considered at any time provided credentials showing increased assets, equipment or ability to perform work are submitted. These credentials must
be submitted at least five (5) working days prior to a bid opening to receive consideration for that bid opening. Contractors shall also report any substantial increase in liabilities
that occurs during the prequalification period.

6. Request for Plans, Specifications and Proposal Form.

Contractors having been duly prequalified will receive notices inviting submission of proposals for contracts to be let on specified dates. A contractor desiring to receive plans,
proposal and specifications for any contract may obtain them upon written request only, utilizing the special form entitled, “Standard Form – Request for Proposal and/or Plans.”
This form is furnished to all prequalified contractors by the Agency. Entries on this form must show the status of all work under contract or otherwise prosecuted by the
contractor, both inside and outside the State of Vermont, as of the date of request. If this form is not completely or properly executed, the Agency reserves the right to refuse
issuance of a proposal form. All forms submitted by a duly prequalified contractor must utilize the company name as stated in their Prequalification Questionnaire. During the
renewal period the Committee will not consider requests to exceed the ratings or classifications of an expired Annual Prequalification or hear requests for revision or appeals of
expired ratings or classifications.

7. Joint Venture Prequalification.

Two (2) or more contractors, who have each prequalified by filing separate statements and who wish to combine all or a portion of their assets for bidding on a single project, may
do so by filing with the Agency of Transportation a Joint Venture affidavit on forms furnished by the Agency upon request, setting forth their desire to be prequalified jointly on a
specific contract. These forms must be received by the Agency not less than ten (10) working days prior to the time advertised for the opening of bids. A Request for Proposal
shall be submitted for the proposed Joint Venture entity. The members of a joint venture may combine their work classifications. The Maximum Dollar Capacity Ratings (MDCRs)
of a Joint Venture shall be the arithmetic sum of the MDCRs of the members minus the dollar value of all other work for all clients that the members are currently obligated to
perform, both individually and as a part of joint ventures.

8. Right Reserved to Refuse Proposal Form.

Proposal forms may be refused for bidding purposes when the contractor’s written request for proposal, showing the amount of all uncompleted work, both inside and outside
of the State of Vermont, and the Agency’s estimate of the amount of work to be bid upon, exceeds the prequalification rating of the contractor. The Agency, acting through the
Prequalification Committee, also reserves the right to refuse issuance of a proposal to any prospective bidder when, in the opinion of the Agency, circumstances, developments,
and/or events have changed the capacity(ies) or qualification(s) of the prospective bidder to successfully perform pursuant to the proposed contract.

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 EXPERIENCE QUESTIONNAIRE

The signatory of this questionnaire guarantees the truth and accuracy of all statements and of all answers to
interrogatories hereinafter made. Use attachments where necessary.

1. How many years has your organization been in business as a general contractor under your present
business name?__________________________ Under other names? ______________________________

2. How many years experience in ________________________construction work has your organization

had: (a) As a General Contractor (b) As a Sub-Contractor

_________________________________________________________________________________________

3. Has your organization, or any officer, partner, director or principal individual thereof ever admitted to or
been convicted of any criminal violation, other than traffic offences; or been convicted of or is currently being
sued for any civil antitrust violation or other civil suit involving fraud; or been debarred from performing work
on any contract? If so, give full details, including the name of any individual involved and the court and docket
number of any civil or criminal actions .____________________ Date of reinstatement ___________________

4. Is your organization currently debarred from performing work on any contract? ___________________
If yes, by whom? ______________________________________Date of reinstatement. ___________________

5. Has your organization ever been denied prequalification? _________________________ If so, by

whom and for what reason?___________________________________________________________________

6. Have you ever failed to complete any work awarded to you? ___________________________________
If so, where and why?________________________________________________________________________
__________________________________________________________________________________________

__________________________________________________________________________________________

7. Has any officer; director or partner of your organization ever been an officer or partner of some other
organization that failed to complete a construction contract?_________________________________________
If so, state name of individual, other organization and reason therefor.__________________________________

8. Has your organization ever received a safety violation citation under the Vermont Occupational Safety
and Health Act, the U.S. Occupational Safety and Health Act, or similar acts in other states.________________

9. Has any officer; director or partner of your organization ever failed to complete a construction contract
handled in his or her own name? _______________________If so, state name of individual, name of owner and
reason therefor._____________________________________________________________________________
__________________________________________________________________________________________

10. List all parent, subsidiaries, affiliates or divisions of your firm, and any related parties included in
disclosures in your most recent financial statements or the notes thereto.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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11. List any of your officers, shareholders or directors that are affiliated with any other contractor and/or
supplier.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

12. Identify all persons having final bidding authority and/or the Chief Estimator
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

13. Identify all persons having authority to represent the organization in person or by correspondence with
the Prequalification Committee or the Administrator.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

14. Give names and complete addresses of major material suppliers and/or subcontractors with whom your
firm has done business in the past three (3) years.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

15. List the names and addresses of the following:

Bank: ____________________________________________________________________________________
_________________________________________________________________________________________
Amount of letter of credit: ____________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Bonding Company and limit (Please specify per project and aggregate limit.): ___________________________
__________________________________________________________________________________________

Bonding Agent: ____________________________________________________________________________

__________________________________________________________________________________________

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16. List specific projects which your organization has completed in the last five (5) years. Attach additional
sheets if required.

Project Name Contract Type of % When Location Contact Person: Name,

Amt. Work Subcon Completed Address and Telephone
Number. of Owner

17. List all field supervisory personnel only, and indicate their construction experience (include resumes if
available):

Individual’s Present Position No. of Years Years of Construction Magnitude and In What
Name or Office With This Firm Experience Type of Work Capacity

18. Is your firm prequalified in any state other than Vermont? If so, please state where and include rating,
and type of work qualified to perform.

State Rating Type of Work

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 EXPERIENCE AND WORK PREFERENCE

In the following table indicate the various types of work in which you are experienced and for which you desire
to be qualified. If projects listed in the five-year project history, above, do not include appropriate disciplines,
please provide additional project references to validate experience.

Type of Work Check Here Type of Work Check Here

Airport Construction Hazardous Material Removal
Bicycle and/or Pedestrian Path Landscaping
Bridge Construction Park & Ride Lot
Bridge Painting Pavement Markings
Bridge Rehabilitation Railroad Bridge Rehabilitation
Building Construction Railroad/Highway Crossing
Building Demolition Railroads
Covered Bridge New Construction Road and Highway
Covered Bridge Rehabilitation Roadway Safety
Crack Sealing/Pavement Maintenance Surface Rehabilitation
Curb & Sidewalk Traffic Signals/Lighting
Drainage Wells
Guard Rail/Fencing/Signs Other (as specified)
 Name of Contractor

ACCOUNTANT’S OPINION

NOTE: Actual bound financial statements from a Certified Public Accountant (not facsimile copies) must be
submitted. All contractors submitting financial information which is prepared “in-house,” or non-CPA,
must submit the following information for this application to be considered:

1. Asset balance sheet.

2. Liabilities balance sheet.
3. Statement of income and retained earnings.

ACCOUNTING FIRM

________________________________________
Name

________________________________________
Address

________________________________________ _________________________________
City State Signature of Accountant

________________________________________ _________________________________
Telephone Number Date

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NOTE: IN ADDITION TO PROVIDING THE CURRENT YEAR FINANCIAL STATEMENT, THIS SHEET MUST BE
COMPLETED BY THE BUSINESS SEEKING PREQUALIFICATION.

Five Year Financial Summary ___________ ___________ ___________ ___________ ___________

Current year 1 yr previous 2 yr previous 3 yr previous 4 yr previous

Revenue

Cost of Revenue

General & Administrative Expenses

Income from Operations

Interest Expense

Other Income

Income before Income Taxes

Income Tax Expense

Net Income

Net Working Capital

Net Plant & Equipment

Long-term Debt

Total Assets

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Construction and Transportation Equipment (at cost less depreciation) $_____________________

Show: Make, Model No., Serial No., How Equipped. (A SEPARATE SCHEDULE MAY BE ATTACHED)

Description Size or Year Year Purchase Depreciation Net Book

Capacity Mfgr. Purchased Price Charged Off Value

Total

Are there any liens, mortgages and/or encumbrances against the above? If so, state total amount $ ___________

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 FILL OUT APPROPRIATE AFFIDAVIT

INDIVIDUAL

AFFIDAVIT FOR INDIVIDUAL

STATE OF _____________________SS:

COUNTY OF ____________________________________________

Being duly sworn, deposes and says that the

foregoing financial statement, taken from his or her books, is a true and accurate statement of his or her
financial condition as of the date thereof and that the answers to the foregoing interrogatories are true; that this
statement is for the express purpose of inducing the party to whom it is submitted to award the submittor a
contract; and that any depository, vendor, surety, or other agency herein named is hereby authorized to supply
such party with any information necessary to verify this statement.
Sworn to before me this _____________________________day of _____________________20___

______________________________________________
(Individual must sign here)

_____________________________________________
Notary Public

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 PARTNERSHIP

If a Partnership, complete this:

Date of organization ____________________________________________

State whether partnership is general, limited or association

_______________________________________________

Name and address of partners:

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

AFFIDAVIT FOR PARTNERSHIP

STATE OF ss:

COUNTY OF

being duly sworn, deposes and says that he or she is a member

(Name of Partner Signing) firm of ;
that he or she is familiar with the books of the said firm

____________________________________________
(Partnership Name) showing its financial condition; that the foregoing
financial statement, taken from the books of the said firm, is a true and accurate statement of the financial
condition of said firm as of the date thereof and that the answers to the foregoing interrogatories are true; that
this statement is for the express purpose of inducing the party to whom it is submitted to award the submittor a
contract; and that any depository, vendor, surety, or other agency herein named is hereby authorized to supply
such party with any information necessary to verify this statement.
Sworn to before me this day of 20

(Name of Partnership) (Partner must sign for firm)

Notary Public

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 CORPORATION

If a Corporation complete this:

President’s Name:

Capital paid in cash: $ Vice-President’s Name:

When Incorporated: Secretary’s Name:

In what State: Treasurer’s Name:

CURRENT BOARD OF DIRECTORS

Appointment Full
Name Position Date Address

OWNERSHIP OF FIRM: Identify only those with five percent (5%) or more ownership.

Years of Ownership Voting

Name Ownership Percentage Percentage

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 AFFIDAVIT FOR CORPORATION

STATE OF ss:

COUNTY OF

being duly sworn, deposes and says that he or she is of the

(Title of Officer)
________________________corporation described in and which executed the foregoing
(Name of Corporation)

statement that he or she is familiar with the books 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 condition of said corporation as of the date thereof and that the answers to the foregoing
interrogatories are true; that this statement is for the express purpose of inducing the party to whom it is
submitted to award the submittor a contract; and that any depository, vendor, surety or other agency herein
named is hereby authorized to supply such party with any information necessary to verify this statement.
Sworn to before me this

day of 20

(Name)

Notary Public

(Officer must sign here)

(Affix Corporate Seal)

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