FORM PQ2 Revised May, 2013x - Wyoming Department of ...

determinedenchiladaΠολεοδομικά Έργα

25 Νοε 2013 (πριν από 3 χρόνια και 11 μήνες)

128 εμφανίσεις



Page
1




FORM PQ
-
2

REVISED
05
/1
3






WYOMING DEPARTMENT OF TRANSPORTATION


REVISED

STANDARD HIGHWAY


PREQUALIFICATION QUESTIONNAIRE




Contractor

s Company Name:
_________________________________________________________


Contractor’s WYDOT Prequalification Number: ___________________________________________





Please read

M
ajor changes to the Prequalification form

have been made
.


This document will take effect
January 1, 2013.













Page
2




Table of Content
s



COVER SHEET


TITLE PAGE
…………….……………………………………………………………………………………………….

P
age 1


TABLE OF CONTENT
S
……………………………………………………………………………………………......

Page
2


PREQUALIFICATION STATEMENT
-

EXPERIENCE
-

EQUIPMENT


ORGANIZATION

(
INSTRUCTIONS
)


P
age
3

-

6


PREQUALIFICATION STATEMENT

(
PREQUALIFICATION STATEMENT EXPERI
ENCE
-

EQUIPMENT


ORGANIZATION
……………………….

P
age
7



1
0


C
ONTRACTOR'S FINANCIAL STATEMENT………………………………………………………………………...

Page 1
1


DECLARATION
PAGE………………………………………………………………………………………………….

Page 1
2


CLASS OF WORK
REQUESTED………………………………………………………………………………………

Page 1
3

-
1
5


WORK CLASSIF
ICATIONS…………………………………………………………………………………………….

Page
1
6



1
8


DISADVANTAGED BUSINESS ENT
ERPRISE STATUS
(E
-
4)………………………………………………………

Page
19


EQUAL EMPLOYMENT OPPORTUNITY AFFIDAVIT (
FR
-
2200)………………………………………………….

Page 2
0 & 21


REQUEST FOR BID ENVELOPES (INSTRUCTIONS)
……………………………………………………………….

Page
22



CURRENT WORK AFFIDAVI
T (FORM
E
-
103)……………………………………………………………………….

Page 2
3


10(A)
CONSTRUCTION PROJECTS YOUR ORGANIZATION HAS

UNDER
WAY AT THIS TIME (EXTRA)….

Page 2
4


20(A) WHAT EQUIPMENT DO YOU OWN THAT IS AVAILAB
LE FOR PROPOSED WORK
?
…………………..
Page 25


PREQUALIFICATION QUESTIONNAIRE
CHECKLIST
……………………………………………………………..

Page 26


























Page
3




PREQUALIFICATION STATEMENT
-

EXPERIENCE
-

EQUIPMENT
-

ORGANIZATION


HIGHWAY CONTRACTOR

PREQUALIFICATION QUESTIONNAIRE INSTRUCTIONS


All persons, firms, co
-
partnerships
,

or corporations proposing to bid on any Wyoming Department of Transportation
WYDOT

construction project must first submit a statement, under oath, on a Prequalification Questionnaire furnished by the Wyoming
Department of Transportation. Such statements
shall fully indicate the Applicant's financial ability, the adequacy of
its
equipment,
organization
,

and past experience, and include any pertinent information necessary to accurately assess the Applicant's status.



WYDOT will not take possession

of
or
retain

the Prequalification Questionnaire if any part of it is incomplete.


The report will
be
returned at the contractor

s expense with
a
letter explaining why it was rejected.


Only the
original

PQ
-
5 will be accepted
. WYDOT cannot
accept

Prequalification forms by e
-
mail or fax.

A copy of the
prequalification for
m

will not be
accepted
.


Unless otherwise requested, a letter will be sent out via e
-
mail notifying the contractor what
its
prequalification status with WYDOT is
when the Prequali
fication form has been reviewed.


Form PQ
-
2 (Prequalification Form) once approved does not approve a contractor to bid on
projects

(
b
uilding)

let through the
WYDOT
Procurement
office

or the WYDOT Engineering Services office
.

The contractor must submit
F
or
m PQ
-
5 for projects let through the
se
office
s
.


Prequalification may be denied
or revoked
if the applicant:


A.

Is declared in default while qualified in accordance with the applicable provisions of any contract issued by the
Department.

B.

Has been
determined to have made false, deceptive, or fraudulent statements during the prequalification process.

C

Has been and is currently under debarment or restricted from bidding
by another government agency
because of
criminal acts or serious breach of contr
act.

D.

Has been disqualified for substantial reasons by another governmental agency.

E.

Has attempted to or has influenced Department policy through gratuities or gifts to WYDOT personnel or by
employing Department personnel.

F.

Has, while qualified, demonstrated an inability to meet WYDOT requirements for specifications and contracts.


Prequalification (Main Office)

Main Headquarters of the c
ompany

that is prequalifing with WYDOT.
If an out of
s
tate
c
ompany
is
qualified a
s a r
e
sident
c
ontractor
, then the Main office and prequalification shall show the
c
ompany’s address in
Wyoming
.
This information
should always be used with the
Electronic Bidding System (
Contractor’s Desktop
)
.


COVER PAGE


The information in the Main office
box

will be used by WYDOT to send out
Contracts, Award Letters,
Addenda,
Notice to
Proceed
,

and P
requalification approval letter
. Plans, Proposals, Plan holders List, Bid Envelopes
,
Addenda
,

and general
correspondence

will go to this address unless an alternative address
is provided.


Alternate Office

This will allow a company

with more than one office to register any office that
it
may use with WYDOT projects. The alternate
office
should never
use
its
information wit
h the
Electronic Bidding System (Contractor’s Desktop)
.


This information in the Alternate
o
ffice will be used by WYDOT to
send out
Plans, Proposals, Plan holders List, Bid Envelopes
,
Addenda
,

and general correspondence

as requested. If the Alternate
o
ffice is requested
,

it will show up on the
p
lan holders list.


PREQUALIFICATION STATEMENT


Provide
satisfactory evidence of compliance with Wyoming Worker’s Compensation Act (W.S. 27
-
14
-
101,
et seq.
) by providing a
current certificate of good standing or proof of a worker’s compensation insurance policy.
F
urnish evidence of compliance with the
Unemployment Insurance Act pursuant to W.S. 27
-
3
-
101 through
W.S.
27
-
3
-
704 by providing a certificate of go
od standing

(
s
ee last
page of this form for ordering information)
.
If
the prequalifing company is
from
out of state

and has never worked in
Wyoming
,


Page
4




provide proof of a worker’s compensation insurance policy

(Certificate of Liability Insurance)
.

Evidence of compliance with these
acts will only have to be submitted at the time of prequalification and will run concurrently with the length of prequalifica
tion and will
only have to be renewed upon the expiration
of the firm’s prequalification.


WYDO
T will not accept

proof of
w
orker

s
c
ompensation,
u
nemployment
i
nsurance

sent to WYDOT from the Department of Work
Force Services.
Certification of
l
iability
i
nsurance

sen
t

to WYDOT will not be accepted as well
. These documents shall to be part of
the Pr
equalification Questionnaire

packet
.


FINANCIAL STATEMENT


All financial information
must

be filed with the Wyoming Department of Transportation within fifteen (15) months of the date of the
Applicant’s fiscal year end
.

(The only pages that are required are:
t
he Accountant

s Report

and

Assets & Liabilit
ies
pages. No
other pages are required unless you are sending in a parent company report, then the subsidiary compan
y’s
Assets &
Liabilities pages are
required
)
.

Only f
inancial statements that have been review
ed or
compiled by a
c
ertified
p
ublic
a
ccountant/
p
ublic
a
ccountant or an audited financial statement by a
c
ertified
public a
ccountant will be accepted.


Prequalification will encompass a 15 month period from the date

of the Applicant’s fiscal year end.

Out
of
date
f
inancial
r
eports will
not be considered as part of the Prequalification statement
, thus

rendering it
incomplete
.
If approved by the Prequalification
Officer, an additional 90 day extension may be granted if the Applicant plans to revise
its
fiscal year.

The extension will be
considered upon receipt of a notarized affidavit from the Applicant
. Extension of prequalif
ication for any other reason will not be
considered or granted
.


The Applicant must show that
it
possesses net current assets of working capital to render it probable that the Applicant can
satisfactorily execute
its
contracts and meet all obligations ther
ein incurred. The Applicant shall authorize the Wyoming Department
of Transportation to obtain all information pertinent to the Applicant's financial standing from financial institutions, sure
ty companies,
equipment dealers or suppliers, or any other pers
ons having financial dealings with the Applicant. The Applicant shall authorize the
aforementioned businesses or individuals to furnish the information requested.




A.

(Page 1) Audited Financial Statement:


T
he net worth of an audited
f
inancial
s
tatement, regardless of amount, will be used to determine the prequalification rating.
The
o
pinion must bear the signature of the
c
ertified
p
ublic
a
ccountant actually performing the financial audit and the
c
ertified
p
ublic
a
ccountant

s

registration number
.




B.

(Page 2) Unaudited Financial Statement, to include a review or compilation:


The net worth of an unaudited
financial s
tatement up to the maximum of
$500,000

is used to determine the prequalification
rating. The net worth in excess of
$500,000

will

not be considered in determining the prequalification rating.
The
o
pinion
must include at least the signature of a
public a
ccountant who is not a member or employee of the Applicant's organization,
n
or a relative of the owner or owners.


The name of your firm as it appears on the
accountant’s f
inancial
s
tatement will be used for prequalification and bidding
purposes. Care must be taken in insuring that your
a
ccountant shows your firm's name properly in the

opinion.


Page 3 of the
financia
l s
tatement in the Questionnaire
must

be signed in
two

(2) places by the Applicant
, one signature at the top (in all
cases) and the other in one of the three remaining categories.


FORM FR
-
2200


Form FR
-
2200 (Equal Employment Opportunity Affidavit) is a re
quired portion of the Prequalification Questionnaire. Form FR
-
2200
(EEO Affidavit) will run concurrently with the length of prequalification, and will only have to be
resubmitted
upon expiration of the
firm’s prequalification or when the firm’s EEO
o
fficer or DBE
l
iaison
o
fficer is changed.


Please n
ote that the duties of the EEO o
fficer must be duties other than normal paper work, and should include duties such as
disseminating EEO policy to
the
firm’s employees.
A DBE
liaison o
fficer is also requir
ed

for all prequalified firms, and the duties
should include soliciting quotes from
c
ertified DBE firms for work to be subcontracted by the firm.

Two
names

are required on page
2 of the FR
-
2200.




Page
5




Prequalification information and ratings are considered con
fidential and may be released only by
c
ourt
o
rder.


Upon receipt of the Prequalification Questionnaire, the Prequalification Officer shall examine and verify the information sub
mitted.
All applications may take up to two weeks once all required informatio
n has been received. A decision regarding the applicant’s
prequalification and rating including the type of work classification

shall be made after all information has been received. Application
status notification will be made by
the
WYDOT Prequalificat
ion Officer.

WYDOT will
not

grant an extension to a prequalified
contractor whose prequalification has expired.


Informal bids are advertised in newspapers or other publications in the locality of the proposed project. These informal bid
s are for
amounts

as determined by the Wyoming Department of Transportation Commission and may be accepted without prequalification
requirements.


I
f
the Applicant is not satisfied with
its
prequalification rating, a written notice from the Applicant must be filed with the
Prequalification Officer requesting a hearing by the Prequalification Committee. The hearing will be held within 30 days of
receipt of
the appeal. The Applicant will be n
otified of the Prequalification Committee's finding within ten (10) days after the hearing. The
Applicant may make a formal request within thirty (30) days to the Wyoming Department of Transportation
e
xecutive
s
taff for a
review of the Prequalification Co
mmittee's finding if not satisfied with the finding of the Prequalification Committee. The Applicant
may make a formal request within thirty (30) days to the Transportation Commission of Wyoming for a review of the
e
xecutive
s
taff's
finding if dissatisfie
d with the finding of the
e
xecutive
s
taff. The Commission’s finding of fact shall be deemed final, binding
,

and

conclusive

without
further recourse.



The Applicant's previous and present job performance will be evaluated by using the Department’s contra
ctor performance evaluation
system to determine the current prequalification rating. Work performed by subcontractors shall be reflected in the contract
or's
performance evaluation.

WYDOT has a prequalification rating system that will apply when
applying
for
prequalification.


A prime contractor will be rated on all work that
it
perform
s

by the
r
esident
e
ngineer using
F
orm PQ
-
1.
Using
F
orm PQ
-
3, the d
istrict
c
onstruction
e
ngineer will average all the PQ
-
1 data
.
All
PQ
-
3’s
for that year will be added
together and an average will be used as
the contractor

s rating. Each year a new rating will be calculated. The old rating will not be carried over unless you have not worked
as a prime or a subcontractor. If a contractor does not work as a prime or a su
bcontractor for three years in a row, then
its
last rating
will be used for a maximum of three years. After the three years
the

rating will go back to a 9. If you have worked
both
as a prime
contractor and subcontractor
,

then
only your rating for being a

prime will be used.



First
t
ime
q
ualifier and has never worked as a
s
ubcontractor

Rating of 9

Work
ed

as a
p
rime

PQ
-
2 Rating each year

Worked only as a
s
ubcontractor in the past three years

9

Worked as a
p
rime and
as
a
s
ubcontractor

PQ
-
2 Rating

Has
worked in the past but not in the last three years

as a prime contractor or a subcontractor

9

Worked with in the last three years but not in the past two years

PQ
-
2 from three years ago


A contractor’s net worth will be multiplied by one of the factor
s

d
escribe
d

above to come up with the

prequalification amount.

If a
contractor receives a rating
of 16 or
less, WYDOT has the right to limit the prequalification amount the contractor can be qualified for.


The Applicant requesting a Proposal Envelope will
be required to submit a Current Work Affidavit (Form E
-
103) and indicate the
total dollar value of all work under contract or subcontract regardless of the contracting agency
.


The current
p
requalification will be
determined by sub
tracting

the current work remaining to be completed from the Applicant's maximum prequalification rating.


If all the criteria of the prequalification regulations are met, and if the proposed project will not exceed the prequalifica
tion amount, a
Proposal Envelope will be issued if the Applicant is prequalified for the type of work on the proposed project. The

applicant shall be
considered eligible for a particular type of work as long as such work comprises at least
30 percent of the applicant company’s own
work force. Materials purchased for items to be subcontracted or placing other contractor’s employees o
n the applicant payroll will
not be considered as part of the 30 percent.

WYDOT

will not allow subcontracting of more than
30 %

of the contract as established in
the project contract.


For more information about forming a joint venture,
please contact the

prequalification office at 307
-
777
-
4056.


The Department shall issue a joint venture proposal envelope to prequalified applicants upon request. WYDOT requires a compl
eted
Form E
-
103 from
EACH

firm in the joint venture before it issues the proposal envelo
pe.
If the joint venture has any company that is
not

a Wyoming registered company, then the state preference will not apply.



Page
6





Nothing herein contained shall be
construed to

deprive the
Transportation Commission of Wyoming
of the right to reject any bid
or

to
refuse to award a contract to the low bidder whe
n
circumstances or developmen
ts have, in the opinion of the
Commission, changed the
qualification or responsibility of the bidder.


If you reside in Wyoming and wish to be considered a
resident c
ontractor
, your residency eligibility must be certified by the
Department of Employment, Division of Labor Standards. Questions regarding residency should be directed to the Division of L
abor
Standards, 1510 East Pershing Boulevard, Cheyenne, WY 82001, or phone (3
07)777
-
7261.


Prequalification for AML work will cover all aspect of the prequalification. The PQ
-
2 (Standard Highway Contractor Prequalification
Questionnaire and Financial Statement for Bidders) will have to be filed with the Wyoming Department of Trans
portation
Prequalification

office. AML representatives will determine if a contractor’s prequalification amount can be changed to perform the
work financially. The prequalification statement that is filed with the Wyoming Department of Transportation wil
l encompass a 15
month period from the date of the Applicant’s fiscal year end.


Questionnaires, correspondence
,

and questions regarding highway contractor prequalification will be directed to:


Prequalification Officer

Construction Program

5300 Bishop
Boulevard

Cheyenne, WY 82009
-
3340

(307)777
-
4056


The E
-
103
-

Current Work Affidavit and the Work Classification information sheet
s
are being provided for your use
.

The E
-
103 is
for WYDOT lettings only
.
Please

retain this form for your use. (Do not ret
urn with your Prequalification

form
.
)





Ensure all information is attached prior to sending in the Prequalification form
.

WYDOT will not take possession
of
or hold onto the Prequalification Questionnaire if any part of it is
incomplete.

























Page
7




P
REQUALIFICATION STATEMENT


EXPERIENCE
-

EQUIPMENT
-

ORGANIZATION


Prequalification (Main Office)


Firm Name: __________________________________________________________________________


Physical Address:
_____________________________________________________________________


Mailing Address: _____________________________________________________________________


City: _______________________ State: ______________________ Zip Code: ___________________


Phone
Number: ________________________________ Fax Number: __________________________


Name of Company Presidents: Mr.
G

Mrs.
G

____________________________________________


Company E
-
Mail Address (Where you want all Addenda to be sent): _____________________
_____


UPS/FED EX Number (Required): _______________________ Phone Number: _________________



Alternate Office


Firm Name: __________________________________________________________________________


Physical Address:
_____________________________________________________________________


Mailing Address: _____________________________________________________________________


City: _______________________ State: ______________________ Zip Code: ___________________


Phone
Number: ________________________________ Fax Number: __________________________


Name of Company Presidents: Mr.
G

Mrs.
G

____________________________________________


Company E
-
Mail Address (Where you want all Addenda to be sent): _____________________
_____




Attach additional sheets if necessary
.


Use the Alternate office(s) lines if you wish the plans, proposals, bid envelopes, plan holders list
,

and addenda to go to
another part of the company. List out all the offices you might use with WYDOT proj
ects.


Please Note: The
i
nformation in the Main Office area will be used by WYDOT to send out all Contracts, Award Letters,
Notice to proceed
, and P
requalifications.







Page
8




PREQUALIFICATION STATEMENT


1.

Do you
have an
y

outstanding
A
-
65
(
s) that have not been turned into
WYDOT? Yes
G

No
G


**
If yes, then your prequalification will be processed
,

but you will not be able to bid or subcontract
until all

E
-
65(s)
have been
turned in and any money that is owed to WYDOT has been
paid
.

See item 2, page 30 of the Standard Specification for Road and
Bridge Construction
**


2.

Have you filed a
WYDOT

Prequalification St
atement in the past? Yes
G

No
G


3
.

W
ere
your company’s
g
ross
r
eceipts less than $22,400,000

for the last fiscal year? Yes
G

No
G


4
. How many years has your organization been in business as a general contractor under your present business name?

____________




5
.
How many years' experience in construction
work
does
your organization
have?



A
s a
Prime

Contractor
:

________________
____

,

or
A
s

a Sub
-
c
ontractor
: ____
_______
________________________


6
.

Is your company a:

Corporation

G

Co
-
partnership

G

LLC/LLP

G


An Individua
l

G

7
. Corporation or Co
-
partnership


If a corporation, answer this:











Date incorporated:
_________________________________________________________________________________________


In what state:

______________________________________________________________________________________________

8
.
LLC/LLP


If Co
-
partnership,
LLC
,
LLP
,

or Individual

answer this


Date of organization:
_______________________________________________________________________________________


State whether partnership is general, limited
,

or association: __________________________________________________


9
.

What is the construction experience of the princi
pal individuals of your organization?


Individual's Name

(Corporation)

Years of Construction Experience

President



Vice
-

President



Secretary



Treasurer



LLC

Partners (LLC)



Partners (LLC)



Partners (LLC)



Partners (LLC)



Partners (LLC)


















Page
9







1
0
.

List the construction projects your organization has under way
at

this
time
:


Contract Amount


Type

of Work

Per
c
ent
Complete


Name
,
Address
,

and Phone Number

of Owner or Contracting Officer





Name:

Address:

Phone:





Name:

Address:

Phone:





Name:

Address:

Phone:





Name:

Address:

Phone:





Name:

Address:

Phone:

A
dditional sheet

on back


1
1
. List projects your organization has completed in past three years:


Contract Amount


Class of Work

When
Completed


Name
,

Address
,

and Phone number

of Owner

















































Use additional sheets as necessary:






Page
10






1
2
. Have you ever failed to complete any work awarded to you?

____________________
_ If

so, where and why
? _
___________
________
_
____


____________________________________________________________________________________________________________________


1
3
. Has any officer or partner of your organization ever been an
officer or partner of some other organization that failed to complete a

c
onstruction

contract?
_________

If so, state name of individual, other organization
,

and reason for not completing contract.
_____________
__
_


1
4
. Ha
ve
any officer
s

or partner
s

of your organization ever failed to complete a construction contract handled in
their
own name?

______
___
___



14
a.
If
so, state name of individual, name of
o
wne
r
,

and reason for not completing
contract.
_______________________
____________
____


_______________________________________________________________________________________________________________________


1
5
. In what other lines of business are you financially
invested
?

___________________________________________________________________


_______________________________________________________________________________________________________________________


1
6
. Name of individuals, companies, or corporations owning 10% or more of applicant's firm.
_________________________________________


_______________________________________________________________________________________________________________________


1
7
. Owners, officers, partners
,

or individuals holding office or having financial interest in another firm prequalified with the Wyoming

Department of Transportation.


______________________________________________________________________________________________________________________
_


1
8
.

List all
s
ubsidiaries of the
organization
:


_______________________________________________________________________________________________________________________


_______________________________________________________________________________________________________________________


19
.

What equipment do you own that is available for proposed work?


Quant.


Item


Description, Size, Capacity, Etc.


Condition

Years of
Service


Present Location



































































































Page
11




Use additional sheets as necessary:




















CONTRACTOR'S FINANCIAL STATEMENT


Please note

When
sending in a financial statement, send
only
the Auditor

s Report

and the
Assets & the Liabilities pages.
WYDOT does
not need the entire report. If you are sending a financial report for a subsidiary company
,

then
WYDOT
will need to have the supplement
al

financial report for that company and not the parent company.






































Page
12





The undersigned hereby declares:


Information furnished regarding the experience, organization, equipment
,

and administration of the applicant is declared to be true as of the date
given. The applicant further declares that the applicant is not in default on any current contract with any contracting agen
cy and is not in a debarment
proceeding or debarred by a
ny governmental agency. The applicant if debarred during the duration of this prequalification period will notify the
Wyoming Department of Transportation of that debarment action no
t later than ten days following
notification of said debarment

and t
hat t
he
f
inancial
s
tatement provided

a true statement of the financial condition of the individual, co
-
partnership or corporation herein first named, as of the
date herein first given; that this statement is for the express purpose of inducing the party to who
m it is submitted to award the submitter a contract;
and that any depository,

vendor
,

or other agency herein
named is hereby authorized to supply such party with any information necessary to verify this
statement.



(REQUIRED)
___________________________
__
_
_______________




Applicant Must Sign Here



(REQUIRED)
_______________________________________________



Title of Person Signing



(REQUIRED)_______________________________________________






Date



AFFIDAVIT FOR INDIVIDUAL


STATE OF






SS.:

COUNTY OF














B
eing

duly
sworn

deposes and says that the foregoing financial information, taken from
his or her
books, is a true and accurate statement of
his or her
financial condition as of the date thereof.


Sworn to before me this
_________

day of

_______________________________________________________

______________, ______________



(Individual must also sign here)



_______________________________________________________

Notary Public


AFFIDAVIT FOR
CO
-
PARTNERSHIP/LLC


STATE OF






SS.:

COUNTY OF














, b
eing

duly
sworn
,

deposes and says that the foregoing financial information, taken from
their books, is a true and accurate statement of their financial condition as of the date thereof.


Sw
orn to before me this _________ day of

_______________________________________________________

______________, ______________



(Member of Firm must also sign here)



_______________________________________________________

Notary Public


AFFIDAVIT FOR
CORPORATION


STATE OF






SS.:

COUNTY OF














, b
eing

duly sworn, deposes and says that the foregoing financial information, taken from
its
books, is a true and accurate statement of
its
financial condition as of the date thereof.


Sworn to
before me this _________ day of

_______________________________________________________

______________, ______________



(Member must also sign here)



_______________________________________________________



Page
13




Notary Public


Form E
-
1




Rev.
1/
11

WYOMING DEPARTMENT OF TRANSPORTATION


TYPE OF
CLASS
IFICATION
REQUESTED


WORK CLASSIFICATIONS:

The equipment must be owned by the firm, member of the firm
,

or firm that
has an interest in the prequalified firm. Rental/
l
eased equipment will be considered if a letter from the
r
ental/
l
easing agency explain
ing

precisely what equipment the contractor is allowed to rent/lease

and what
equipment has been rented in the past from them
.

See pages 16
-
18 for description of the diff
erent
w
ork
c
lassifications.


Only the items that are marked will be considered for the Prequalification Classification.
The c
ontractor must
show equipment to support any item that is checked,
whether
owned, leased
,

or rented.

(Explanation of each
item ca
n be found on pages 4, 5
,

and 6 of the E
-
1 form
.
)

GRADING





NAICS

CODE

MISCELLANEOUS GRADING
…………………………………………………..

(

)


238910


MINOR GRADING
……………………………………………………………….

(

)

238910

GRADING

(WYDOT
and/or

AML)
……………………………………………….

(

)

238910

RCP (REINFORCED
CONCRETE PIPE)
………………………………………...

(

)

238120

CMP (CORRUGATED METAL PIPE)
…………………………………………...

(

)

237310

SURFACING





NAICS CODE

TRUCK HAUL
…………………………………………………………………….

(

)

484200

MINOR
CRUSHING
………………………………………………………………

(

)

333120

MAJOR

CRUSHING
………………………………………………………………

(

)

333120

GRAVEL SURFACING
…………………………………………………………...

(

)

484200

CHIP SEAL
………………………………………………………………………...

(

)

237310

MICROSURFACING
………………………………………………………….…..

(

)

237310

CRACK SEALING
………………………………………………………………...

(

)

237310

SEAL
COAT
……………………………………………………………………….

(

)

237310

SLURRY SEAL
……………………………………………………………………

(

)

237310

MINOR ASPHALT SURFACING
………………………………………………...

(

)

237310

ASPHALT SURFACING
………………………………………………………….

(

)

237310


CONCRETE SURFACING

CONCRETE SURFACING (STREETS)
…………………………………………..

(

)

237310

CONCRETE SURFACING
………………………………………………………..

(

)

237310

RUMBLE STRIPS
…………………………………………………………………

(

)

237310



Page
14




SURFACE TEXTURING
………………………………………………………….

(

)

237310

BRIDGES/STRUCTURES





NAICS CODE

MINOR CONCRETE STRUCTURES (BOX
CULVERTS)
……………………...

(

)

237310

MINOR BRIDGE WORK
…………………………………………………………

(

)

237310

CONCRETE STRUCTURES (BRIDGES)
………………………………………..

(

)

237310

STEEL STRUCTURE
S……………………………………………………………

(

)

237310

STRIPING (INCLUDING BUT NOT LIMITED TO)





NAICS CODE

PAINT (WA
TER BOURNE AND SOLVENT BASE)
……………………………

(

)

237310

THERMAL PAINTING
……………………………………………………………

(

)

237310

EPOXY BASE PAINTING
…………………………………………………
...
…...

(

)

237310

THERMOPLASTIC APPLICATION
……………………………………………...

(

)

237310

GUARDRAIL





NAICS CODE

BOX BEAM/W


BEAM
…………………………………………………
……
….

(

)

237310

CABLE
……………………………………………………………………………..

(

)

237310

FENCE





NAICS CODE

BARBED WIRE FENCE
…………………………………………………………..

(

)

238990

WOVEN WIRE FENCE
…………………………………………………………...

(

)

238990

INDUSTRIAL FENCING
………………………………………………………….

(

)

238990

SNOW FENCE
…………………………………………………………………….

(

)

238990

SIGNING





NAICS CODE

ROADWAY SIGNING
…………………………………………………………….

(

)

237310

OVERHEAD SIGNING
…………………………………………………………...

(

)

237310

LANDSCAPING





NAICS CODE

SOD
………………………………………………………………………………...

(

)

561730

IRRIGATION
………………………………………………………………………

(

)

561730

TREES/BUSHES
…………………………………………………………………..

(

)

561730

SEEDING/RECLAMATION
………………………………………………………

(

)

561730

UNDERGROUND UTILITIES





NAICS CODE

WATER LINES
……………………………………………………………………

(

)

237110

SEWER LINES
…………………………………………………………………….

(

)

237110

STORM SEWER
…………………………………………………………………..

(

)

237110

CABLE:

(
ELECT
,
TELE, FIBER OPTIC,

COM)
………………………………...

(

)

237130



Page
15




GAS
………………………………………………………………………………...

(

)

237130

ELECTRICAL WORK





NAICS CODE

TRAFFIC SIGNAL
………………………………………………………………...

(

)

238210

OVERHEAD SIGN
………………………………………………………………...

(

)

237310

LUMINARIES
……………………………………………………………………..

(

)

238210

ITS

…………………………………………………………………………………

(

)

237130

MISCELLANEOUS CONCRETE WORK





NAICS CODE

SIDEWALK
………………………………………………………………………..

(

)

237310

CURB & GUTTER
……………………………………………………...…………

(

)

237310

WINGWALLS
……………………………………………………………………..

(

)

237310

DRILLED SHAFTS
-

TRAFFIC SIGNAL/LIGHTING/SIGN:


(
UP TO
24" DIAMETER)
………………………………………………….....

(

)

237310

DRILLED
SHAFTS:


(CAISSONS
OVER
24" DIAMETER)
……………………………………
..

(

)

23
8910

MISCELLANEOUS WORK




ROCKFALL MITIGATION
……………………………………………………….

(

)

237990

SOILS STABILIZATION & SHORING
…………………………………………..

(

)

237990

GENERAL





NAICS CODE

ALL WORK EXCLUDING ELECTRICAL
……………
…………………………

(

)


237310


OTHER

(Indicate types of

Wor
k):
_
_
___________________________
___________________________________________________

____________________________________________________________________________________________________________

___________________________________________________________

The PQ
-
5 (Standard Building Contractor Prequalification
for Bidders) will be used to
prequalify

b
uilding
contractors.
All building projects will be
pre
qualified as
they
come up for bid.












Page
16




WYDOT

CLASSIFICATIONS


GRADING

(
WYDOT/
AML)

MISCELLANEOUS GRADING:

Firm has only
b
ackhoes,
l
oaders, rollers
,

and
from
1
to
3 haul style
trucks
(not less than 8 yards)
to perform work. 15,000± CY or less


MINOR GRADING:

Firm has from 1 to 3 scrapers or 4
to
8 haul style trucks (not less than 8 yards) plus the
support equipment (loaders, rollers, motor graders, water trucks). 100,000± CY or less


GRADING

(
WYDOT and/or
AML)
:

Firm
must have

4 or more major scrapers of 20+ CY capacity or 8 or
more haul style
trucks (not less than 8 yards) plus the support equipment (loaders, rollers, motor graders, water
tr
ucks). Greater than 100,000+CY


RCP/CMP:

Firm has
e
xcavators,
backhoes, l
oaders
,

and r
ollers or compaction equipment (
j
umping
j
acks,
p
late
t
ampers, etc).


SURFACING

T
RUCK HAUL
:
Firm must own at least
4
trucks (not less than 8 yards)
capable of hauling construction
material.


MINOR CRUSHING
: Firm has a small capacity crushing plant that will produce less than 100 ton/hour or
less of material.


MAJOR
CRUSHING:

Firm has
a
crushing plant that will produce more that 100 tons/hour of materia
l
.


GRAVEL SURFACING:

Firm must have at least 1 roller,
a
motor grader
,

and at least
4
trucks (not less than 8
yards) capable of hauling construction material.


CHIP S
EALING:

Firm must have a
s
elf
propelled c
hip
s
preader, distributor, 4 or more haul t
r
ucks (8 cubic
yards or more)

mechanical brooms
,

and rubber tire rollers.


MICROSURFACING:

Firm must have a microsurfacing machine
and
4 or more haul
t
r
uck
s

(8 cubic yards or
more).


CRACK SEALING:

Firm must have routers, compressors
,

and tar pots.


MINOR ASPHALT SURFACING:

Firm must have either a
hot p
lant capable of producing less than 100
tons/hour or a laydown machine. All j
obs must be less than 5,000 t
on
s
, except if documentation is provided to
demonstrate that several larger projects have been successfully completed and adequate equipment is available,
such as but not limited to, laydown machine, rollers, distributor
,

etc.


ASPHALT SURFACING:

Firm must have a
h
ot
p
lant capable of producing 100 tons/hour or more, laydown
machines, distributor and rollers
, and
4 or more haul
trucks

(8 cubic yards or more).


CONCRETE SURFACING (STREETS):

Firm must have a
b
ridge
deck m
achine or
have concrete p
avi
ng
equipment without a
c
oncrete
p
lant.




Page
17




CONCRETE SURFACING:

Firm must have a
concrete p
lant and a
r
oadway type
c
oncrete
l
aydown
m
achine
with support equipment.


BRIDGE/STRUCTURES

MINOR CONCRETE STRUCTURES

(BOX CULVERTS):

Minor classification for firms that indicate they
want to be classified for
b
ridges, but do not have the equipment. (Included are prefab or precast structures up to
60 feet long
.
)


MINOR BRIDGE REPAIR:
Minor classification for bridge work. This classification will be used for but
not
limited to the following: a
pproach
slabs, b
ridge

r
ailing,
ex
pansion
j
oint
r
epair
,
b
ridge
d
eck
r
epair, etc.
Firm

must have forms, vibrators, air compressors, small jack hammers, etc.


CONCRETE STRUCTURES (BRIDGES):

Firm must have
a
p
ile
h
ammer,
c
rane (a minimum of 18 tons
capacity),
baskets, f
orms
,

and
a
b
ridge
d
eck
m
a
chine plus the
capabilities of doing concrete.

(Included are
prefab, precast
,

or cast
-
in
-
pl
ace structures greater than 60

feet

long).


STEEL STRUCTURES:

Firm must have
a
p
ile
hammer, c
rane (a minimum of 18 tons capacity),
b
askets
,

and
f
orms to place steel structures.


STRIPING

URBAN:

Truck mounted st
riper with a minimum capacity of 120 gallons and support equipment.


HIGHWAY:

Truck mounted striper with a heating system, minimum capacity of 300 gallons, bead a
pplicator
,

and support equipment
.


OTHER CLASSIFICATIONS

GUARDRAIL:

Minor classifications needing only small equipment, truck, loader
,

or tractor to perform.


FENCING:

Minor classifications needing only small equipment, truck, loader
,

or tractor to perform.


SIGNING:



ROADWAY SIGNING:

Minor classifications needing on
ly small equipment, truck, loader
,

or
tractor to perform.

OVERHEAD SIGNING:
Minor classifications needing only small equipment, truck, loader,
tractor
,

and a small crane to perform.


LANDSCAPING:


Minor classifications needing only small equipment, truck,

loader
,

or tractor to perform.


UNDERGROUND UTILITIES:

WATER LINES:

Firm has
e
xcavators,
b
ackhoes,
l
oaders,
r
ollers, compaction equipment (
jumping jacks, p
late
t
ampers, etc
.
)
, and
a trench box.


SEWER LINES:
Firm has
e
xcavators,
b
ackhoes,
l
oaders,
r
ollers or
c
ompaction equipment (
j
umping
jacks,
plate t
ampers, etc
.
)
, and
a trench box.


STORM SEWER:

Firm has
excavators, b
ackhoes

and
l
oaders
,
r
ollers or
c
ompaction equipment (
jumping
j
acks,
plate t
ampers, etc
.
)
, and
a trench box.




Page
18




CABLE (ELECTRICAL, GAS
, TELEPHONE, FIBER):
Firm has
excavators, backhoes, l
oaders,
t
renchers,
r
ollers or compaction equipment (
j
umping
j
acks,
plate t
ampers, etc
.
)
, and
a trench box.


ELECTRICAL WORK:

Firm has
e
xcavators,
b
ackhoes,
l
oaders,
t
renchers,
r
ollers
,

or compaction equipment
(
j
umping
jacks, plate p
ampers, etc
.
). The firm shall also have a member of the firm
who
is a licensed
m
aster
e
lectrician (must be shown on Prequalification form)
and
a trench box.



MISCELLANEOUS CONCRETE WORK

CURB
and
GUTTER, SIDE
WALK:

Firm must have forms or a slip form machine.


WINGWALLS:

Firm must have forms and support equipment


DRILLED SHAFTS (Less than 24

inches
):
Firm must have a drill truck.


DRILLED SHAFTS (Greater than 24

inches
):
Firm must have a drill truck capable o
f drill
ing a
shaft larger
than 24

inches
in diameter.


GENERAL WORK:

Firm must have all equipment to accomplish all phases of
grading, s
urfacing
, and
b
ridges. Electrical work will be excluded in this item. This classification does not include
b
uilding
w
ork.































Page
19




F
orm E
-
4

Rev. 11/99


WYOMING DEPARTMENT OF TRANSPORTATION

DISADVANTAGED BUSINESS ENTERPRISE STATUS


Is your firm owned, managed
,

and controlled by
disadvantaged i
ndividuals? Yes ( ) No ( )


If yes, please check
the applicable group:


( )

Native American

-

a person having origins in any of the original peoples of North America, which
included American Indians, Eskimos, Aleuts, and Native Hawaiians, and maintains cultural
identification through tribal affiliatio
n or community recognition.


( )

Black American

-

a person having origins in any of the Black racial groups of Africa.


( )

Hispanic American

-

a person of Mexican, Puerto Rican, Cuban, Dominican, Central or South
American, or other Spanish or Portugu
ese culture or origin, regardless of race.


( )

Asian
-
Pacific American

-

a person having origins in any of the peoples of Japan, China, Taiwan, Korea,
Burma (Myanmar), Vietnam, Laos, Cambodia (Kampuchea), Thailand, Malaysia, Indonesia, the
Philippines,
Brunei, Samoa, Guam, the U.S. Trust Territories of the Pacific Islands (Republic of Palau),
the Commonwealth of the Northern Marianas Islands, Macao, Fiji, Tonga, Kirbati, Juvalu, Nauru,
Federated States of Micronesia, or Hong Kong.


( )

Subcontinent As
ian Americans

-

a person having origins in any of the original peoples of India,
Pakistan, Bangladesh, Bhutan, the Maldives Islands, Nepal
,

or Sri Lanka


( )

Female


( )

Other

-

members of other groups, or other individuals found to be economically
and socially
disadvantaged by the Small Business Administration under Section 8(a) of the Small Business Act, as
amended
(
15 U.S.C. 637
[
a
])
.


If you checked yes,
and
are a member of one of the above groups and wish to be apply for certification as a
Disadv
antaged Business Enterprise, please contact:


DBE Certification Officer

Wyoming Department of Transportation

Civil Rights Office

5300 Bishop Boulevard

Cheyenne, WY 82009
-
3340

(307)777
-
4457









Page
20




F
R
-
2200

Page 1 of 2

Rev. 10/09

EQUAL EMPLOYMENT OPPORTUNITY

AFFIDAVIT

CONTRACTOR:


PROJECT:

Contractor
Prequalification

DATE:



DOES HEREBY CERTIFY, THAT OUR COMPANY DOES AND WILL ADHERE TO THE EQUAL EMPLOYMENT OPPORTUNITY REQUIREMENTS NOT
TO DISCRIMINATE AND TO TAKE AFFIRMATIVE ACTION TO ASSURE EQUAL EMPLOYMENT OPPORTUNITY AS REQUIRED BY EXECUTIVE
ORDERS 11246 AND 11375 AS SET FOR
TH IN REQUIRED CONTRACT PROVISIONS
23CFR §230, FHWA
-
1273
,
(FORM PR
-
1273) AND THE SPECIAL
PROVISION
SS
-
100E, (SPECIFIC EQUAL EMPLOYMENT OPPORTUNITY REQUIREMENTS AND TRAINING PROVISIONS)
,

AND THAT OUR
COMPANY WILL WORK WITH THE WYOMING DEPARTMENT OF TRANSPOR
TATION IN CARRYING OUT EQUAL EMPLOYMENT OPPORTUNITY
OBLIGATIONS AND IN THE WYOMING DEPARTMENT OF TRANSPORTATION'S REVIEW OF OUR ACTIVITIES UNDER THE CONTRACT AND THAT
OUR COMPANY AND ALL SUBCONTRACTORS HOLDING SUBCONTRACTS, NOT INCLUDING MATERIAL SUPPLIERS
, WILL COMPLY WITH THE
SPECIFIC REQUIREMENT ACTIVITIES OF EQUAL EMPLOYMENT OPPORTUNITY SET FORTH IN THE SPECIAL PROVISIONS.


OUR COMPANY WILL FURTHER DISSEMINATE THE EQUAL EMPLOYMENT OPPORTUNITY POLICY OF THE COMPANY AT LEAST EVERY SIX
MONTHS TO ALL
MEMBERS OF OUR STAFF WHO ARE AUTHORIZED TO HIRE, SUPERVISE, PROMOTE
,

AND DISCHARGE EMPLOYEES OR WHO
RECOMMEND SUCH ACTION OR WHO ARE SUBSTANTIALLY INVOLVED IN SUCH ACTION. WHEN SEEKING EMPLOYEES, OUR COMPANY WILL
MAKE KNOWN TO OUR PRESENT EMPLOYEES, POTEN
TIAL SOURCES OF EMPLOYEES,
SUCH AS
SCHOOLS, EMPLOYMENT AGENCIES, LABOR
UNIONS (WHERE APPROPRIATE), COLLEGE PLACEMENT OFFICERS, THE COMPANY'S EEO POLICY THROUGH THE USE OF APPROPRIATE
POSTERS AND NOTICES IN AREAS READILY ACCESSIBLE TO EMPLOYEES, APPLICANTS
FOR EMPLOYMENT
,

AND POTENTIAL EMPLOYEES.


WHEN ADVERTISING FOR EMPLOYEES, OUR COMPANY WILL INCLUDE IN ALL ADVERTISEMENTS FOR EMPLOYEES, THE NOTATION "AN
EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER
.
" ADVERTISING WILL BE DONE IN NEWSPAPERS OR OTHER PUBLICATIONS H
AVING A
SUBSTANTIAL OR LARGE MINORITY CIRCULATION.


RECRUITMENT OF EMPLOYEES WILL BE MADE THROUGH PUBLIC AND PRIVATE EMPLOYEE REFERRAL SOURCES LIKELY TO YIELD
QUALIFIED MINORITY AND FEMALE GROUP APPLICANTS. WE WILL THROUGH OUR EEO OFFICER IDENTIFY SOURCES

OF POTENTIAL
MINORITY AND FEMALE GROUP EMPLOYEES AND ESTABLISH WITH SUCH IDENTIFIED SOURCES PROCEDURES
THAT
WILL PROMOTE THE
REFERRAL OF MINORITY AND FEMALE APPLICANTS. THE COMPANY WILL ENCOURAGE PRESENT EMPLOYEES TO REFER MINORITY AND
FEMALE APPLICANTS
BY POSTING APPROPRIATE NOTICES OR BULLETINS IN ACCESSIBLE AREAS AND BY DISCUSSING REFERRAL
PROCEDURES WITH PRESENT EMPLOYEES.


OUR COMPANY FURTHER ASSURES THAT WAGES, WORKING CONDITIONS
,

AND EMPLOYEE BENEFITS SHALL BE ESTABLISHED AND
ADMINISTERED, AND PERS
ONNEL ACTIONS OF EVERY TYPE, INCLUDING HIRING, UPGRADING, PROMOTION, TRANSFER, DEMOTION, LAYOFF
,

AND TERMINATION, SHALL BE TAKEN WITHOUT REGARD TO RACE, COLOR, RELIGION, SEX
,

OR NATIONAL ORIGIN. WE WILL MAKE
INSPECTIONS AT LEAST EVERY MONTH DURING CONSTRU
CTION TO INSURE THAT WORKING CONDITIONS AND EMPLOYEE FACILITIES DO
NOT INDICATE DISCRIMINATORY TREATMENT OF PROJECT SITE PERSONNEL. WE WILL REVIEW PERSONNEL ACTIONS TO GUARD AGAINST
DISCRIMINATORY ACTIONS AND WILL TAKE CORRECTIVE ACTION WHERE REQUIRED.


A
LL COMPLAINTS OF DISCRIMINATION WILL BE INVESTIGATED IMMEDIATELY AND CORRECTIVE ACTION TAKEN WHERE NECESSARY.


WE WILL ASSIST IN LOCATING, QUALIFYING
,

AND INCREASING SKILLS OF MINORITY AND FEMALE GROUP EMPLOYEES AND APPLICANTS
FOR EMPLOYMENT.


WE WILL MAKE

USE OF TRAINING PROGRAMS, PRE
-
APPRENTICESHIP, APPRENTICESHIP, AND/OR ON
-
THE
-
JOB TRAINING PROGRAMS FOR THE
GEOGRAPHICAL AREA OF CONTRACT PERFORMANCE, CONSISTENT WITH THE NEEDS AND ORGANIZATION OF OUR COMPANY AND AS
PERMISSIBLE UNDER FEDERAL AND STATE REGUL
ATIONS. WE WILL ADVISE EMPLOYEES AND APPLICANTS FOR EMPLOYMENT OF
AVAILABLE TRAINING PROGRAMS. WE WILL REVIEW THE TRAINING AND PROMOTION POTENTIAL OF MINORITY AND FEMALE GROUP
EMPLOYEES. WE WILL ENCOURAGE ELIGIBLE EMPLOYEES TO APPLY FOR SUCH TRAINING AN
D PROMOTION.


WE WILL, IN RELYING IN WHOLE OR IN PART UPON UNIONS FOR EMPLOYEES, USE OUR BEST EFFORTS TO PROMOTE THE TRAINING AND
QUALIFYING OF MINORITY AND FEMALE INDIVIDUALS FOR MEMBERSHIP IN UNIONS.


WE WILL USE OUR BEST EFFORTS TO PROMOTE THE INCORPORA
TION OF EQUAL EMPLOYMENT OPPORTUNITY CLAUSES INTO ALL UNION
AGREEMENTS.






Page
21




F
R
-
2200

Page 2 of 2

Rev. 10/09



WE WILL THROUGH OUR DBE LIAISON OFFICER SEEK OUT AND PROVIDE MAXIMUM SUBCONTRACT OPPORTUNITY TO DISADVANTAGED
BUSINESS ENTERPRISES
IN ACCORDANCE WIT
H SPECIAL PROVISION SS
-
100F (DISADVANTAGED BUSINESS ENTERPRISE
PARTICIPATION)
. WE WILL REQUIRE ALL SUBCONTRACTORS TO COMPLY WITH THE EQUAL EMPLOYMENT REQUIREMENTS OF THIS
CONTRACT.



(1)

WE WILL DISSEMINATE SUBCONTRACT INFORMATION TO DBE FIRMS KNOWN TO
PERFORM THE TYPE OF WORK TO BE
SUBCONTRACTED.



(2)

WE WILL FURNISH THE WYOMING DEPARTMENT OF TRANSPORTATION WITH THE NAMES AND ADDRESSES OF ALL DBE
FIRMS THAT WILL BE PARTICIPATING IN THE PROPOSED CONTRACT.



(3)

WE WILL PROVIDE THE WYOMING DEPARTMENT OF
TRANSPORTATION WITH A DESCRIPTION OF THE TYPE OF WORK AND
AMOUNT OF WORK BY DOLLAR VOLUME THAT EACH DBE FIRM WILL BE PERFORMING.



(4)

WE WILL PROVIDE A LIST OF DBE FIRMS CONTACTED IN THE PROCESS OF SOLICITING QUOTATIONS FOR WORK TO BE
SUBCONTRACTED, THE T
YPE OF WORK TO BE SUBCONTRACTED
,

AND THE INDIVIDUAL RESPONSE RECEIVED FROM THE
DBE FIRMS CONTACTED.


WE WILL MAINTAIN AND PROVIDE ALL REQUIRED RECORDS. INFORMATION TO BE PROVIDED WILL INCLUDE THE NUMBER OF MINORITY,
FEMALE, AND NON
-
MINORITY GROUP MEMBERS
EMPLOYED IN EACH WORK CLASSIFICATION ON THE PROJECT. WHEN UTILIZING UNIONS,
THE PROGRESS AND EFFORTS BEING MADE IN INCREASING MINORITY AND FEMALE GROUP EMPLOYMENT OPPORTUNITIES; THE PROGRESS
AND EFFORTS BEING MADE IN LOCATING, TRAINING, QUALIFYING
,

AND UP
GRADING MINORITY AND FEMALE GROUP EMPLOYEES; THE
PROGRESS AND EFFORTS BEING MADE IN SECURING THE SERVICES OF DISADVANTAGED BUSINESS ENTERPRISE SUBCONTRACTORS WITH
MEANINGFUL DISADVANTAGED GROUP REPRESENTATION AMONG THEIR EMPLOYEES. ALL SUCH RECORDS WILL B
E KEPT FOR A PERIOD
OF THREE YEARS FOLLOWING COMPLETION OF THE CONTRACT WORK AND WILL BE AVAILABLE AT REASONABLE TIMES AND PLACES FOR
INSPECTION BY AUTHORIZED REPRESENTATIVES.


OUR COMPANY WILL SUBMIT TO THE WYOMING DEPARTMENT OF TRANSPORTATION FORM PR
-
139
1, AN ANNUAL REPORT EACH JULY, WHEN
THERE ARE EMPLOYEES WORKING ON THIS PROJECT DURING JULY. THE REPORT WILL INDICATE THE NUMBER OF MINORITY, FEMALES,
AND NON
-
MINORITY GROUP EMPLOYEES CURRENTLY ENGAGED IN EACH WORK CLASSIFICATION REQUIRED BY THE CONTRACT
WORK.


THE COMPANY ALSO CERTIFIES THAT THE FOLLOWING STATEMENT IS ACCEPTED AS OPERATING POLICY DESIGNED TO FURTHER THE
PROVISION OF EQUAL EMPLOYMENT OPPORTUNITY TO ALL PERSONS WITHOUT REGARD TO THEIR RACE, COLOR, RELIGION, SEX
,

OR
NATIONAL ORIGIN, AND TO P
ROMOTE THE FULL REALIZATION OF EQUAL EMPLOYMENT OPPORTUNITY THROUGH A POSITIVE CONTINUING
PROGRAM:


"IT IS THE POLICY OF THIS COMPANY TO ASSURE THAT APPLICANTS ARE EMPLOYED, AND THAT EMPLOYEES ARE TREATED
DURING EMPLOYMENT, WITHOUT REGARD TO THEIR RACE, CO
LOR, RELIGION, SEX
,

OR NATIONAL ORIGIN. SUCH ACTION SHALL
INCLUDE: EMPLOYMENT, UPGRADING, DEMOTION, OR TRANSFER: RECRUITMENT OR RECRUITMENT ADVERTISING: LAYOFF OR
TERMINATION: RATES OF PAY OR OTHER FORMS OF COMPENSATION: AND SELECTION FOR TRAINING, INCLU
DING
APPRENTICESHIP, PRE
-
APPRENTICESHIP, AND/OR ON
-
THE
-
JOB TRAINING."


CONTRACTOR COMPANY NAME
(
REQUIRED
)
:
__________________
____________________
_______________________________
_
_________


________________________________
____
_________________,
_________________________
____
________________, __________
____
________



Signed By:








Title:





Date:


COMPANY EQUAL EMPLOYMENT OFFICER
(
REQUIRED
)
:

__________
____________________________________________
____________


(Name of EEO Officer)


___________________________________________________________
_________
________________________,(__________)______
_
_____________

(Business Address)


(24 hour Telephone Num
ber)


COMPANY DBE LIAISON OFFICER
(
REQUIRED
)
:

_______
_____________________________________________________________________

(Name of DBE Liaison Officer)


______________________________________________________________
__________
_____________________,
(__________)_______________
__
__



(Business Address)



(Telephone Number)



Page
22






Bid envelope requirements



1.

T
o receive a bid envelop, the contractor must
:


A.

B
e prequalified,


B
.

Have a p
requalification
that
will not run out
before
the bid letting

for which
the envelope is
being requested
,


C.

M
eet the minimum
monetary
qualif
ication
,


D.

M
eet the minimum
work classification,


E
.

The applicant shall be considered eligible for a particular type of work as long as such work
comprises at least 30 percen
t of the applicant company’s own work force. Materials purchased
for items to be subcontracted or placing other contractor’s employees on the applicant payroll
will not be considered as part of the 30 percent
.


The current p
requalification
amount
will be determined by subtracting the current work remaining to be
completed from the Applicant's maximum prequalification rating.





































Page
23





Form E
-
103

10
/2012

WYOMING
DEPARTMENT OF TRANSPORTATION

Requests for bid envelopes will only be accepted when using this form.


CURRENT WORK AFFIDAVIT

Submit this form if your firm is currently prequalified and is requesting a bid envelope to bid as a
prime

contractor on a project
currently advertised. Please submit this form to:



State Construction Office








Wyoming Department of Transportation

(or)

F
AX to the same at:

(or)

E
-
Mail to



5300 Bishop Blvd.


(307)777
-
4765


dot
-
construction@wyo.gov

(“Bid

C
heyenne, WY 82009
-
3340




Envelope Request”) in subject box


For the


,


Letting we request Bid
Envelopes for the

following call

order
number
(
s
):


(Call
Order Number
(s) Requested
):
_______________
________________________________________________________________



List all construction work, regardless of who the contracting agency or owner is, with the exception of
miscellaneous work
$10,000.00 and under. If miscellaneous work exceeds a combined total of $25,000, show combined total of the
miscellaneous contracts or jobs.


DOLLAR VALUE OF WORK
REMAINING, LESS WORK
SUBCONTRACTED TO OTHERS


TYPE OF WORK


CO
NTRACT OWNER

$



$



$



$



$



$



$



$



$

Total


List additional projects on
a separate page
if necessary.


Address where you would like the Bid Envelope (s) mailed: (Plans must be requested separately)


Shipping Address:
____________________________________________________________________________


City: _________________________ State:________________________ Zip Code _________________


I certify the above information represents the total dollar value of work remaining to
be done, less miscellaneous work, as

per the instructions.


If package is to be sent over night, we need a


NAME (PLEASE PRINT)
:
___________________________________


FED EX/UPS Number:
____________________________

SIGNED
:
_______
__________________________________________

(FED EX will not deliver to P.O. Boxes)


TITLE:

_____________________________
_____________________









COMPANY
:
__________________________________
____________




DATE: ___________________________________________________


FOR WYDOT USE ONLY












Phone Number: ___________________________________________

Contractor ID #:

D
ate Approved:

Reason for not Approving:




Page
24




E
xtra
work sheets



10(A
) Construction

projects your organization has underway at this time:



Contract Amount


Type of Work

Percent
Complete


Name, Address
,

and Phone Number of Owner or Contracting
Officer





Name:

Address:

Phone:





Name:

Address:

Phone:





Name:

Address:

Phone:





Name:

Address:

Phone:





Name:

Address:

Phone:




Name:

Address:

Phone:




Name:

Address:

Phone:




Name:

Address:

Phone:





Name:

Address:

Phone:




Name:

Address:

Phone:




Name:

Address:

Phone:





Page
25






20 (A). What equipment do you own that is available for proposed work?


Quant.


Item


Description, Size, Capacity, Etc.


Condition

Years of
Service


Present Location



























































































































































































































Page
26







PREQUALIFICATION QUESTIONNAIRE CHECKLIST



1.

A copy of your Worker

s Compensation
a
ccount from Wyoming or proof of a worker’s
compensation insurance policy is attached. Prequalification will not be approved unless your
firm has proof of current coverage.



Department of Employment

Worker’s Safety and Compensation Division

1510 East Pershing Boulevard

Cheyenne, WY 82001

(307)777
-
6763


2.

Proof that you are in compliance with the Wyoming Unemployment Insurance Act.



Department of Employment

Unemployment Ta
x Division

P.O. Box 2760

Casper WY 82602
-
2760

(307)235
-
3217



Do not have
a
copy sent to WYDOT. WYDOT
will not

accept

them. These reports must be part of
your prequalification packet.


3.

If you
r

company is out of state,

and has never worked in Wyoming,
a copy of the
CERTIFICATE OF LIABI
LITY INSURANC
E
may take the place of Wyoming Worker

s
Compensation and Unemployment Insurance.


4
.

The section on your available equipment is completed or you have attached an equipment list.


5
.

Page 12 needs to be signed on the top and notarized in one
of the
areas below
.


6
.

Y
ou have attached a copy of the prepared
Financial S
tatement from you
r

accounting firm;


7
.

You have signed page
12
of the Financial Statement portion in two

(2) places.


NOTE:
Your financial statement
cannot

be older than 15 months.


8
.

Form FR
-
2200, EEO Affidavit, is attached and completed in its entirety.


9
.

If you are a Wyoming resident, you have filed with the Wyoming Department of Employment,

Department of Labor Standards for residency status. If you have not filed, your firm will be

considered a non
-
resident firm for the purposes of bidding.


10.

Do not return the E
-
103 (
CURRENT WORK AFFIDAVIT)
. The E
-
103 is turned in
only
if
you are
requesting a bid envelope for the current month’s letting.


Make sure all information

(
Signatures, Notary Stamps, Financial statements
[
if you are not using
the ones provided
]
, etc.
)

are
attached prior to sending in the Prequalification form.