Contractors Experience Questionnaire

Community Development & Services Agency
Department of Public Works
EXPERIENCE QUESTIONNAIRE
(Page 1 of 2)
Rev 07-24-08
Organization Name:
Mailing Address:
Business Address:
Owner Name(s):
Contact Name:
Phone Number(s):
Fax Number:
Email Address:
New Submittal Change of Information Annual Re-submittal
NOTE:
• Information provided on this questionnaire will be used to place your company on a Bidders list for Public Works
Construction Projects. The list will indicate the type(s) of work provided by each company and will be made available
to the public upon request.
• A copy of your Certificate of Liability Insurance must be attached with your submittal Experience Questionnaire form.
1. How many years has your organization been in business under your present business name
2. Type of Road Construction your organization provides:
Grading Paving Underground (Storm Drain) C&G, S/W (Concrete) Signage / Striping Seal Coat
Other (Specify):
3. How many years of experience with Road Construction projects has your organization had:
As a general contractor
As a subcontractor
4. Is your organization licensed in the State of California YES (List below) NO
Type Title Class Number
5. List the four most recent projects your organization has had in Road Construction (Public Works Projects Preferred):
Date
Contract Amount Type of Work
Agency Name, Contact Name & Phone
Completed
I understand that by signing this form I am Certifying that all of the information shown hereon is true, correct, and current to
the best of my knowledge.
Print Name
Title
Signature
Date

Community Development & Services Agency
Department of Public Works
EXPERIENCE QUESTIONNAIRE
(Page 2 of 2)
Rev 07-24-08
6. Has any construction contract to which you have been a party been terminated by the Owner; have you ever
terminated work on a project prior to its completion for any reason; has any surety which issued a performance bond
on your behalf ever completed the work in its own name or financed such completion on your behalf; has any surety
extended any monies in connection with the contract for which they furnished a bond on your behalf
YES
NO
If the answer to any portion of this question is “YES”, please furnish details of all such occurrences including the name
of the agency, owner, architect or engineer, surety, and name and date of project on a separate sheet.
7. Has any officer or partner of your organization ever been an officer or partner of any organization that had any
construction contract terminated by the Owner; terminated work on a project prior to its completion for any reason;
had any surety which issued a performance bond complete the work in its own name or finance such completion; or
had any surety expend any monies in connection with the contract for which they furnished a bond
YES
NO
If the answer to any portion of this question is “YES”, please furnish details of all such occurrences including name of
the agency, owner, architect or engineer, surety, and name and date of project on a separate sheet.
8. What is the construction experience of the principal individuals of your organization
Individual Name
Present Position
or Office
Years of
Experience
Magnitude & Type of
Work
In What Capacity
I understand that by signing this form I am Certifying that all of the information shown hereon is true, correct, and current to
the best of my knowledge.
Print Name
Title
Signature
Date