Appendix E: STANDARD FORM: DOTD as modified for Port of New Orleans

Transcription

1 Appendix E: STANDARD FORM: DOTD as modified for Port of New Orleans Professional Services FORM PONOSF Check the contract name these qualifications are submitted for (check only one): 1) As-Needed Engineering and Professional Services for Moveable Bridges 2) As-Needed Bridge Inspection and Load Rating Services for Moveable Bridges and Fixed Railroad Bridges Respondents must submit a separate form for each contract. 3. Firm (as registered with the Louisiana Secretary of State) and mailing address of the office to perform work 2a. Announcement date January 20, b. Project number To be assigned by PONO at a later date 3a. Name, title, telephone number, and address of the official with signing authority for this contract 3b. Name, title,telephone number, and address of full-time professional in charge. 4. List the number and type of full-time professional personnel on firm s payroll in all offices domiciled in Louisiana, who are likely to work under the contract shown in Box 1:

2 5. List the number and type of full-time professional personnel on firm s payroll in all offices not domiciled in Louisiana, who are likely to work under the contract shown in Box 1: 6. Do you presently have sufficient staff to perform the services to undertake this work in the next 30 months? (Yes/No) 7. If available, firm s last DOTD audited overhead rate % Self-imposed overhead limitation (applies to Prime and Sub-consultants for this contract)? (Yes/No) % (For use by prime consultant only) 8. Indicate the percent of the contract to be performed by the prime consultant %. Is prime consultant a certified DBE, WBE, or MBE? Yes/No (For use by the prime consultant only) 9. Do you intend to use a sub-consultant(s) for services, if not shown as 100 percent in Box 8? Yes/No Name and address of each sub-consultant Identify the element of work and the percent of the contract scope of work to be performed by each sub-consultant, and if sub-consultant is a certified DBE, WBE, or MBE. 1. Element of Work to be performed 2. Element of Work to be performed

3 3. Element of Work to be performed 4. Element of Work to be performed 5. Element of Work to be performed 6. Element of Work to be performed 7. Element of Work to be performed

4 10. Staffing Plan A Diagram showing all key personnel that would be available for assignment. The Staffing Plan should also include the same information for sub-consultants (if applicable).

5 11. Brief resume of key persons anticipated to work a. Name & domicile b. Job Title: c. Name of firm by which employed full time d. Years experience: With this firm: With other firms: e. Education: Degree(s) / Years / Specialization f. If applicable, registration/certification: Year registered/certified: Licensed/Certified as: State:. License No.: g. Other experience and qualifications relevant to the proposed work:

6 12. Work by firm which best demonstrates experience relevant to this contract as shown in Box 1 (List no more than 5 projects) a. Project number, name & location b. Project description c. Nature of firm s responsibility & key personnel involved d. Owner s name, address, and telephone number e.firm s Contract Completion Date

7 13. All work by firm (all offices) currently under contract with the Port of New Orleans (as Prime or Sub-consultant) a. Project name b. Type of work provided. c. Percent complete d. Contract lump sum or not-to-exceed fee Total Paid to Date Balance Remaining * For as-needed contracts, list open task orders individually ** Do not include sub-consultant s fees

8 14. Value of Contracts with the Port of New Orleans within the past 24 months As Prime As Sub 15. Use this space to identify the key professional personnel who would be shown in a proposal should your firm be short-listed for the contract shown in Box 1. This section IS NOT to be used to submit proposed prices or rates. FAILURE TO SIGN ITEM 16 WILL RENDER THE RFQ NON-RESPONSIVE 16. This is to certify that all information contained herein is accurate and true. Signature of Authorized Representative (same as 3a) Date