or Print Prequalification/ Certification Application.

Transcription

Write your SSN/EIN on every page of this
application.
New York City School Construction Authority
APPLICATION FOR
PREQUALIFICATION/CERTIFICATION
GENERAL INFORMATION
Name of Applicant Firm:
D/B/A Name, if any:
SSN/EIN:
This business address is:
Home
Building Number:
Business
Both
Street Name:
Suite / Apt.:
City:
Country:
State/Region:
ZIP/Postal Code:
Mailing Address (if different) Note: P.O. Box only acceptable for mailing address.
Street Address: ________________________________________________________________________
City: ______________________________State: ____________________ Zip Code _________________
Company Phone # (not toll-free): ___________________ Company Fax Number _____________________
Web Address: __________________________________________________________________________
Primary Application Contact
Title:
Miss
Ms.
Mrs.
Mr.
Dr.
Contact Person:
Business Title:
Primary Phone:
Home
Office
Cell
Other
Secondary Phone:
Home
Office
Cell
Other
E-Mail Address:
Secondary Application Contact
Title:
Miss
Contact Person:
Primary Phone:
Rev/2/2009
Ms.
Mrs.
Mr.
Dr.
Business Title:
Home
Office
Cell
Other
Page 1
application.
APPLICATION FOR
Secondary Phone:
Home
Office
Cell
Other
E-Mail Address:
Notification of Bidding Opportunities:
E-Mail
Fax
Please Specify:
Solicitation-specific communications:
E-Mail
Fax
Please Specify:
BUSINESS ORGANIZATION & HISTORY - SECTION 1
Type of Organization:
Date Applicant Firm founded (MM/YYYY):
Sole Proprietorship
County in which business certificate is filed:
Please attach a copy of Applicant Firm's business certificate filed with the local County
Clerk's office.
Corporation
State Incorporated:
Date Incorporated:
Number of shares authorized to the corporation:
Number of shares issued to individuals or entities:
Limited Liability Company (LLC)
State Formed:
Date Incorporated:
Number of members of the LLC:
General Partnership
Limited Partnership
Limited Liability Partnership
County where partnership agreement filed:
State where partnership agreement filed:
Rev/2/2009
Page 2
application.
APPLICATION FOR
Joint Venture
State Formed:
Date Formed:
Are all partnering firms qualified by the SCA?
Yes
No
Joint Ventures must submit a prequalification application for the Joint Venture and each JV
partner.
Association
Not for Profit Organization
Professional Corporation
Other
Please specify:
Is the Applicant Firm registered with NYS Division of Corporations?
Yes
No
Is the Applicant Firm currently involved in the bidding process with the SCA or other contract/purchase
order negotiations with any governmental agency, department or authority?
Yes
No
If yes, please identify agency, department, or authority:
Please select from Appendix B ALL trade codes for which you are requesting prequalification, and enter
code(s) in the box(es) below. (The SCA uses these codes to help determine the type and dollar value of
jobs on which you will be able to bid and/or work as a subcontractor.) Please also indicate whether the
average of commercial references for each code is over or under $1 million. For each trade code
selected, you will be required to provide sufficient commercial references for work completed within the
past three (3) years (see Work History & References – Section 2).
<$1m
>$1m
<$1m
>$1m
<$1m
>$1m
<$1m
>$1m
<$1m
>$1m
<$1m
>$1m
<$1m
>$1m
<$1m
>$1m
<$1m
>$1m
<$1m
>$1m
Describe principal products/commodities sold or services offered:
Rev/2/2009
Page 3
application.
APPLICATION FOR
BUSINESS ORGANIZATION & HISTORY - SECTION 2
Identify all locations used by the firm including its office, plant, warehouse, and any other commercial
facility. Also list heavy equipment and machinery.
Type
Own,
Lease, or
Rent?
Address
Name of Landlord or
Mortgage Holder
Affiliation with
Applicant firm or
Key Person
Payment
Terms
At present or during the past five (5) years has the Applicant Firm shared office space, plants,
warehouses, staff, equipment, telephone or fax exchanges, etc. with any other business or organization?
Yes
No
Firm Name
EIN
Address
Nature of Shared
Facility or Staff
Date Range
At present or during the past five (5) years, has the Applicant Firm changed address(es) or operated
under any other name(s) or ownership type?
Yes
No
Firm Name
Rev/2/2009
Ownership Type
Change Type
Address
Date Range
Page 4
application.
APPLICATION FOR
Has your Certificate of Incorporation or Business Certificate been amended?
Yes
No
If yes, please explain:
At present or during the past five (5) years:
a) has the Applicant Firm been a subsidiary or affiliate of any other firm? (answer should be yes if you are
owned by a holding company as well)
Yes
No
b) has the Applicant Firm consisted of a partnership in which one or more partners are other firms?
Yes
No
c) has any other firm owned 5% or more of the Applicant Firm? (includes venture capitalists, holding
companies and other similar investors)
Yes
No
d) has the Applicant Firm joint ventured with any other firms?
Yes
Applies
To (a-d)
No
Firm Name & EIN
Address
Relationship to
Applicant Firm
% of
Applicant
Firm Owned
Date Range
Representative
Name & Title
a) has the Applicant Firm had any subsidiaries?
Yes
No
b) has the Applicant Firm owned 5% or more of any other firm?
Yes
Rev/2/2009
No
Page 5
application.
APPLICATION FOR
Applies
To (a-b)
Firm Name &
EIN
Address
Nature of
Business
% Owned
Relationship to
by Applicant Date Range
Applicant Firm
Firm
KEY PEOPLE & PERSONNEL - SECTION 1
In the following table, provide the requested information for all current key people as defined below, and anyone who
has owned 5% or more of the Applicant Firm within the past five (5) years. Each current key person of the Applicant
Firm must attach a notarized certification (e.g., Appendix A, etc.). Also, please attach a resume for each key person.
"Key People" include:
Proprietor(s), partners, directors, officers, members.
Partners, including general, limited and limited liability.
Members - admitted as members of a limited liability company (LLC) and have a membership interest in the LLC.
Membership interest is a member's aggregate rights in an LLC, including, without limitation, the member's right to a
share of the profits and losses of the LLC and the right to vote and participate in the management of the LLC.
Any person in a position to control and direct the firm's overall operations and financial decisions.
Signatories to bank accounts, whether or not considered "Key People."
Holders of licenses necessary for the Applicant Firm to perform SCA work for which it is seeking Prequalification.
Corporations Publicly held corporations should list the President, Treasurer, Chief Financial Officer, shareholders of 5% or
more of the firm's issued stock, and only those officers and managers who will have direct responsibility for SCA
contracts. Shareholders are owners of 5% or more of issued stock or other securities (stock options, secured or
unsecured bonds, warrants rights) that can be converted to stock that, if exercised, would constitute 5% or more
of the firm's issued stock.
Non-publicly held corporations should list all Corporate Officers and all Shareholders (owners of 5% or more of
authorized shares).
Be sure to include all those who fit the definition of Key People. Please note that subsequent questions may
pertain to present and past Key People within the time periods specified in the question. The term "Key Person",
as defined above, controls throughout this application.
Copy the table on the following page if more space is required. Provide current proper legal name and specify
any name change, including maiden or married names or aliases.
Rev/2/2009
Page 6
application.
APPLICATION FOR
Table of Key People
(complete all boxes, provide resume for each current Key Person listed)
Key Person #1
Key Person #2
Key Person #3
Title & Name
Home Phone # and
Address
Date of Birth
Social Security Number
Alien Registration
Number, if not a U.S.
Citizen
Business Title
Employment Start Date
Commencement Date of
Current Position
Employment End Date
Percentage of Ownership
& Total Amount/Value of
Contributions
Number of shares owned
Date shares were
acquired
Method of Acquisition &
Amount paid when
purchased
Specify any name
change, maiden name, or
aliases
Gender
Ethnicity
Page 7
Each current Key Person of the Applicant Firm must file a NOTARIZED certification on the form attached (Appendix
A) and submit a resume. Please attach Alien Registration Number Documentation
You may copy this page as necessary.
Rev/2/2009
application.
APPLICATION FOR
KEY PEOPLE & PERSONNEL - SECTION 2
Please identify those individuals responsible for managerial operations.
Financial Decisions:
First / Last Name
Business Title
Sex / Group Code*
M
F /
M
F /
Owner or
Non-Owner
Estimating:
First / Last Name
Business Title
Sex / Group Code*
M
F /
M
F /
Owner or
Non-Owner
Preparing Bids:
First / Last Name
Business Title
Sex / Group Code*
M
F /
M
F /
Owner or
Non-Owner
Negotiating Bonding:
First / Last Name
Business Title
Sex / Group Code*
M
F /
M
F /
Owner or
Non-Owner
Preparing Insurance:
First / Last Name
Business Title
Sex / Group Code*
M
F /
M
F /
Owner or
Non-Owner
* Please use the following Group Codes:
01
02a
02b
02c
Rev/2/2009
Black
Hispanic
Portuguese
Spanish
03a Asian - Pacific
03b Asian - Indian
04 Native American
Page 8
application.
APPLICATION FOR
Please select the key people and/or personnel added in the previous section (e.g., officers, partners,
owners, members, managers, supervisor, field personnel, or professionals) that possess experience in
the trade code(s) selected earlier in this application. Note: Vendors are not required to submit
resumes.
Name
Total Years of Related
Experience
Field of Expertise
Total Years with Firm
Please identify the cash and capital contributions including gifts, equipment, loans, and expertise to the
firm by those identified in above, as well as any other individuals.
Contributor/Source
Amount/Value
Type of Contribution
Date of Contribution
At present or during the past five (5) years, has any Key Person served as a Key Person or owned 5% or
more of any other firm (including firms that are inactive, dissolved, or non-construction-related)?
Yes
Key Person &
Position Held
Rev/2/2009
No
Other Firm
Name,
Address &
EIN
Nature of
Business
Is this person % Owned by
an owner?
Key Person
Y
N
Y
N
Y
N
Y
N
Remainder
Owned By
Date Range
Served or
Owned
Page 9
application.
APPLICATION FOR
Are any Key People of the Applicant Firm:
a) present or past employees of the NYC School Construction Authority (SCA)?
Yes
No
b) related by kinship or marriage to any present or past employee of the SCA?
Yes
No
c) related by kinship or marriage to anyone who is a key person in a firm that has sought prequalification
from the SCA?
Yes
No
Applies To (a-c)
Key Person
Name of Current or Past
SCA Employee
Relationship
Do any office staff, field/supervisory staff, estimators, controllers, or consultants also work for another
firm?
Yes
No
Type of Personnel
Name
Other Firm Name
Other Firm Address Other Firm Phone #
Did the current owners purchase the assets of the firm or acquire the firm pursuant to a written purchase
or buyout agreement or assignment? If yes, firm may be required to provide a copy of the agreement or
assignment upon request.
Yes
No
If yes, provide the following:
Previous owner(s) names(s):
Has the purchase price been paid in full?
Date Purchased:
Rev/2/2009
Yes
No
Page 10
application.
APPLICATION FOR
WORK HISTORY & REFERENCES - SECTION 1
Please list below and provide copies (front and back) of all licenses, registrations, certifications, etc.
necessary for work the Applicant Firm will perform. Note each licensee must be identified as a key
person in this application.
Individual/Corporation
License/Certification
Named on
Number
License/Certification
License Name
Issued By
Expiration Date
WORK HISTORY & REFERENCES - SECTION 2
In the section below, state the number of projects and the total dollar amount of the Applicant Firm's
sales/revenue for each of the past three (3) fiscal or calendar years.
Calendar
Fiscal
If fiscal, provide last fiscal year end (MM/YYYY):
Year
Number of Projects/Contracts
Completed During the Year
Total Sales/Revenues for the Year
Total Number of Employees (please average over the past year):
Permanent
Temporary
Full-Time
Part-Time
In this section, provide information for commercial prime contracts or commercial subcontracts completed
within the last three (3) years. (Work history will be used by the SCA to determine for which Master
Format code(s) the Applicant Firm qualifies and the dollar threshold, if any). All projects must be valued
at more than $25,000.
If you are prequalifying AND certifying (MWLBE) for the first time, you must provide a minimum of two
(2) commercial references for each trade code selected.
If you are prequalifying AND certifying (MWLBE) for the first time and are seeking qualification for work
Rev/2/2009
Page 11
application.
APPLICATION FOR
in excess of $1 million, you must provide a minimum of four (4) commercial references averaging $1
million for each trade code selected.
If you are prequalifying ONLY (first time or requalifying), you must provide a minimum of four (4)
commercial references for each trade code selected.
Project #1
Project #2
Project #3
Agency/Owner/Developer
General Contractor on
Project
Project Name and
Address
Project Contract #
Work Performed on
Project*
Applicant Firm's Contract
$ Amount
Start and Completion
Date of Applicant Firm's
Contract
Representative from
Agency/Owner/Developer
Familiar with
Performance**
Title and Phone # of
Representative
Were You a Prime or a
Sub?
Project Completed in a
Disadvantaged Area?
Prime
Y
Sub
N
Prime
Y
Sub
N
Prime
Y
Sub
N
Trade Codes***
*Firms must indicate specifically the work performed and in what capacity, e.g., subcontractor,
general contractor, construction manager, etc.
**Representative cannot be affiliated or related to any key people of the applicant firm.
***Choose trade codes from those previously entered on this application.
Rev/2/2009
Page 12
application.
APPLICATION FOR
FINANCIAL INFORMATION - SECTION 1
Does firm have a CPA/Accountant?
Yes
No
CPA/Accountant for Firm
Name:
Phone # (not toll-free):
CPA/Accountant's Address:
City:
State:
ZIP/Postal Code:
Please enter information for each local business bank account held by the Applicant Firm in the space provided.
In addition, please attach a separate sheet listing any other domestic, foreign and/or offshore business bank
accounts held by the Applicant Firm.
Name on Account
Type of Account
Bank Name and Address Names of ALL Signatories*
*Note: Signatories must be Key People.
Does the Applicant Firm have a bonding capacity?
Yes
No
Provide information for all surety companies that have currently agreed to furnish the Applicant Firm with
performance and payment bonds. Please also attach a bonding letter (see Appendix C for sample) for
each surety.
Surety Name and
Address
Rev/2/2009
Names & Addresses
Agent/Broker Name
Aggregate
of Others Whose
Single Job Bonding
and Phone # (not
Bonding Capacity
Indemnity the Surety
Capacity ($)
toll-free)
($)
Company Relies On
Page 13
application.
APPLICATION FOR
Does the Applicant Firm carry errors and omissions insurance?
Yes
No
Errors & Omissions Insurance
Company Name: ____________________________________________________________________
Address: __________________________________________________________________________
City: _______________________________________ State/Region _______ Zip code ____________
Agent: ___________________________________________ Phone #: _________________________
Policy Limits: ______________________
Single: _________________
Aggregate ($): ______________
Does the Applicant Firm carry professional liability insurance?
Yes
No
Professional Liability Insurance
Company Name:
Address:
City:
State/Region:
ZIP/Postal Code:
Agent:
Phone #:
Policy Limits:
Single ($):
Aggregate ($):
At present or during the past five (5) years have there been any errors or omissions or professional
liability claims against the Applicant Firm?
Yes
Insurance
Type
Rev/2/2009
No
Insurer
Date Claim
Filed
Claimant
Claim
Amount
Disposition
Summary/Details
Page 14
application.
APPLICATION FOR
Does the applicant firm have a line of credit and/or an unsecured or secured loan provided by a lending
institution?
Yes
No
Amount of
Credit
Amount Owed
Revolving Line of
Credit?
Y
N
Y
N
Y
N
Y
N
Termination
Date
Name of Lending
Institution
Loan Officer Name
and Phone # (not
toll-free)
a) has the Applicant Firm been indebted, either formally or informally, to an individual or entity other
than a commercial lending institution in the cumulative amount of $50,000 or more?
Yes
No
b) have any of the Applicant Firm's Key People been indebted, either formally or informally, to an
individual or entity other than a commercial lending institution in the cumulative amount of $50,000
or more, for the benefit of the Applicant Firm?
Yes
No
c) has any individual or firm been a guarantor, co-maker or co-signer of any of these obligations on
behalf of the Applicant Firm?
Yes
Applies
To (a-c)
No
Name of
Creditor
Name of
Borrower
Amount of Balance
Loan
Owed
Terms of
Pledge or
Loan
Name of
Guarantor or Date Range
Co-Signer
At present or during the past five (5) years, has the Applicant Firm, its Key People or Affiliate Firm(s):
a) been the subject of a judgment of $50,000 or more by a subcontractor, supplier, labor union,
benefit fund or other creditor?
Yes
Rev/2/2009
No
Page 15
application.
APPLICATION FOR
b) been a party to a bankruptcy or reorganization proceeding?
Yes
No
c) had any delinquent local, city, state or federal taxes outstanding?
Yes
No
Applies Agency/Owner
To (a-c)
Involved
Agency/Owner
Phone # (not
toll-free)
Case # &
Docket #
Court &
County
Description of
Circumstances
Current
Status
At present or in the past five (5) years has the Applicant Firm or any of its Key People or Affiliate Firm(s):
a) loaned the cumulative amount of $50,000 or more, either formally or informally to an individual or
entity?
Yes
No
b) paid any commission or fee of any kind to anyone who is not a Key Person of the firm for the
purpose of obtaining contracts or work?
Yes
Applies
To (a-b)
No
Receiver Name and
Address
Amount Loaned
Amount Paid
Reason for
Loan/Payment
Date Range
Has the Applicant Firm ever failed to complete a contract due to the following?
a) Financial Constraints, including Bankruptcy
Yes
No
b) Non-Compliance with Loan Covenant
Yes
Rev/2/2009
No
Page 16
application.
APPLICATION FOR
c) Non-Compliance with Surety Covenant
Yes
Applies
To (a-c)
No
Agency
Involved
Contract
Number
Date of Action
Description of Action
Agency Contact Name
and Phone # (not
toll-free)
SAFETY - SECTION 1
Please provide the following information for the previous calendar year:
# of Construction Employees:
Hours Worked:
Does the Applicant Firm have a written safety program? If yes, please attach.
Yes
No
Provide the name and title of the highest-ranking employee of the Applicant Firm responsible for safety.
Please also attach any relevant safety certifications/licenses.
Name:
Title:
Please provide the following information and documents for the previous calendar year:
EMR (Experience Modification Rating):
# OSHA Recordable Cases:
Total Days Away from Work:
# Fatalities:
Attach letter from insurance carrier or information page from worker's compensation policy indicating
firm's EMR, as well as OSHA 300 Log.
Rev/2/2009
Page 17
application.
APPLICATION FOR
SAFETY - SECTION 2
In the section below, list the number of violations issued by OSHA as "Serious," "Willful," "Repeat," or
"Failure to Abate Penalty" for the current year and the past five (5) years. List the number of OSHA
violations in each category for each year. Go to www.osha.gov for further information.
Number of OSHA Citations
Year
Serious
Willful
Repeat
Failure to Abate
For each violation, attach a copy of the initial OSHA violation report (must include violation date,
type, violation number, and nature of violation) and provide the status/outcome (including penalty
or fine paid or pending) and additional details, if any.
Has the Applicant Firm made a payment or paid a fine to settle any other OSHA violations without an
admission of guilt?
Yes
No
If yes, please explain:
APPRENTICESHIP
At present or within the past three (3) years, has the Applicant Firm had a labor agreement with any labor
union/organization with jurisdiction in the City of New York or participated in a New York State
Department of Labor approved Apprentice Program?
Yes
Rev/2/2009
No
Page 18
application.
APPLICATION FOR
Labor Union or
NYS-DOL Approved
Apprenticeship
Program
Local Number
Number of Years
Affiliated
Date Range
Affiliated
Apprenticeship
Program
For each apprenticeship, attach supporting documentation.
INTEGRITY - SECTION 1
At present or during the past five (5) years, has any Key Person, employee or any consultant of the
Applicant Firm served as an elected official, political party officer, community board or district school
board officer, or non-elected governmental appointee or employee of the New York City Department of
Education (formerly the Board of Education), or New York City or New York State government?
Yes
No
Individual Name
Position
Name of
Organization
Relationship
Date Range
At present or during the past five (5) years, has the Applicant Firm, or any current or past Key People or
Affiliate Firm(s) been the subject of any of the following actions by any government agency?
a) Been suspended, debarred, disqualified, had its Prequalification revoked or otherwise been
declared ineligible or not responsible to bid or to perform work for any reason, including failure to
cooperate with any government agency?
Yes
No
b) Been barred from bidding or denied a contract as a result of refusal of Key People to testify
before a grand jury, administrative board or agency?
Yes
No
c) Been barred from bidding or denied a contract as a result of failure to meet statutory affirmative
action or Minority/Women/Local Based/Disadvantaged/Small Business Enterprise requirements?
Yes
Rev/2/2009
No
Page 19
application.
APPLICATION FOR
d) Been denied a contract despite being the low bidder for any reason?
Yes
No
e) Defaulted or been defaulted on any contract?
Yes
No
f) Had a contract terminated?
Yes
No
g) Been given a final unsatisfactory performance determination or deemed a poor performer (by
letter or formal proceedings)?
Yes
No
h) Been prevented, barred or agreed to voluntarily refrain from bidding for any reason?
Yes
No
i) Been denied a contract for failure to obtain surety or otherwise provide required security?
Yes
No
j) Had liquidated damages assessed against it upon completion of a contract?
Yes
No
k) Either withdrawn or had any business related licenses, certificates or certifications revoked,
rescinded, surrendered, suspended or otherwise restricted or sanctioned by a licensing body or
agency?
Yes
No
List #1
List #2
Applies To (a-k)
Agency
Contract Number
Date of Action
Description of Action
Key People Involved
Agency Contact Person
Name and Phone #
(not toll-free)
Applies To
(check all that apply)
Applicant Firm
Key Person(s)
Affiliate (Please Specify)
Applicant Firm
Key Person(s)
Affiliate (Please Specify)
If yes, supply details and attach supporting documentation.
Rev/2/2009
Page 20
application.
APPLICATION FOR
If yes to any questions in this section, supply details and attach supporting documentation.
At present or during the past five (5) years, has the Applicant Firm, or any current or past Key People or
Affiliate Firms:
a) been a plaintiff, defendant, petitioner or respondent in any lawsuits arising out of a public or
private construction project?
Yes
No
b) been a plaintiff, defendant, petitioner or respondent in any lawsuit with any governmental agency,
including ERISA actions?
Yes
No
c) been a plaintiff, defendant, petitioner or respondent in any lawsuit concerning an allegation of
unfair or unethical business practices?
Yes
Applies
To (a-c)
No
Caption or
Action
Plaintiff or
Defendant
Court
Index/Docket
Number
Date
Status and
Summary
Plaintiff
Defendant
Plaintiff
Defendant
Plaintiff
Defendant
Plaintiff
Defendant
At present or during the past ten (10) years has the Applicant Firm, or any of its current or past Key
People or Affiliate
Firm(s):
a) been under any investigation concerning an alleged violation of criminal law?
Yes
No
b) been advised that any of them were the target or subject of an investigation involving any
violations of criminal law?
Yes
No
c) been notified that any Key Person's communications or those of Applicant Firm or any of its
Affiliate Firms were intercepted or that telephone instruments or premises used by any such person
or entity were the subject of court ordered electronic surveillance?
Yes
No
d) been arrested, indicted or named as a defendant or unindicted co-conspirator in any complaint,
indictment or other accusatory instrument?
Yes
Rev/2/2009
No
Page 21
application.
APPLICATION FOR
e) been convicted, after trial or by plea, of any felony under local, state or federal law?
Yes
No
f) been convicted of any misdemeanor concerning business-related conduct or involving moral turpitude?
Yes
No
g) pleaded to a violation or entered a plea of nolo contendere to a charge concerning or related to
embezzlement, theft, forgery, bribery, falsification or destruction of records, receiving stolen
property or a violation of the antitrust law?
Yes
No
h) entered into a consent decree, been the subject of a court order, including but not limited to preliminary
or permanent injunctions or restraining orders, restricting or concerning business-related conduct, or
retained an individual or entity to monitor the safety and/or business operations of the applicant firm, or
entered into an agreement with an Independent Private Sector Inspector General (IPSIG)?
Yes
No
i) been granted immunity from prosecution or from the use of any testimony by court order or the action of
a grand jury?
Yes
No
j) invoked the Fifth Amendment in response to any question as a witness in any legal proceeding before
any court, grand jury, or other governmental agency?
Yes
No
k) been promised by any prosecutor, orally or in writing, that their statements or testimony would
not be used against them?
Yes
Applies
To (a-k)
Rev/2/2009
No
Agency or Court
Involved
Nature of
Action
Name and
Address of
SSN/EIN of
Person/Entity Filing Date
Person/Entity
Named
Named
Status or
Outcome
Page 22
application.
APPLICATION FOR
For the purposes of answering this question only, do not include violations of the Occupational Health and
Safety Act (OSHA), which will be addressed in the Safety section of this application.
At present or during the past ten (10) years has the Applicant Firm, any of its current or past Key People
or Affiliate
Firm(s):
a) been the subject of an investigation, or named as a defendant in a lawsuit, by a public agency
concerning any alleged civil violation of a state or federal anti-racketeering, organized crime control
or antitrust statute (including, but not limited to the Federal Racketeering Influenced Corrupt
Organization law, and the New York State Crime Control Act)?
Yes
No
b) been the subject of an investigation by any public regulatory agency including, but not limited to,
the U.S. Department of Housing and Urban Development (HUD), the U.S. Environmental Protection
Agency (EPA), the U.S. Securities and Exchange Commission (SEC), the U.S. Immigration and
Naturalization Service or the equivalent public agencies of any state?
Yes
No
c) been the subject of an investigation or any other administrative, statutory or regulatory violations?
Yes
No
d) been the subject of an investigation or paid a fine or made a payment to settle any of the above
without an admission of guilt?
Yes
No
e) had any administrative charges filed by any public agency that are pending as of the date of this
application?
Yes
Applies
To (a-e)
Rev/2/2009
No
Agency or Court
Involved
Name and
Nature of
Address of
SSN/EIN of
Investigation/
Person/Entity
Person/Entity
Charges
Named
Named
Date of
Charges
Status or
Outcome
Page 23
application.
APPLICATION FOR
or Affiliate Firm(s) been under investigation or cited for, entered into a settlement agreement concerning
or found to have committed a violation of any local, state, or federal labor law or regulation including
prevailing wage rates and fair labor practices?
Yes
No
Agency or Court
Involved
Nature of
Violation
Name and
SSN/EIN of
Person/Entity
Named
Address of
Person/Entity
Named
Date of Charges
Status or
Outcome*
*If fined, indicate amount and status - e.g., paid, outstanding.
or Affiliate Firm(s) engaged in any of the following conduct:
a) filed with, or submitted to a government agency, or any employee or representative thereof, by
any means, including, but not limited to, telefax, e-mail, or any other form of electronic
communication, any document which any Key Person of the Applicant Firm knew to contain a false
statement or false information?
Yes
No
b) falsification of business records?
Yes
No
c) given, or offered to give, money, gifts or anything of value or any other benefit to a labor official or
public servant with intent to influence that labor official or public servant with respect to any of his or
her official acts, duties or decisions as a labor official or public servant?
Yes
No
d) given or offered to give, money, gifts or anything of value or any benefit to a labor official or
public servant for any reason?
Yes
No
e) given, or offered to give, money or other benefit to an official or employee of a private business
with intent to induce that official or employee to engage in unethical or illegal business practices?
Yes
Rev/2/2009
No
Page 24
application.
APPLICATION FOR
f) received or been approached to receive money, gifts, other inducement or anything of value from an
employee or officer of a private business for the purpose of inducing a key person to engage in unethical
or illegal business practices?
Yes
No
g) agreed with another person to submit a proposal or price or bid below prevailing market rate?
Yes
No
h) agreed with another person to submit identical or complimentary bids, prices or proposals or otherwise
not to bid competitively or agree to withdraw or abstain from bidding?
Yes
No
i) agreed with another person not to submit competitive bids, prices or proposals in another's territory
established either by geography or customers?
Yes
No
j) agreed with another person to take turns in obtaining contracts by pre-determining which firm shall
submit the lowest bid, price or proposal?
Yes
No
Applies To
(a-j)
Describe in Detail
Key People Involved
Date Range
LBE QUALIFICATION
How many workers do you currently employ?
# African American Employees:
# Hispanic Employees:
# Asian Employees:
# White Employees:
# Other Ethnicity Employees:
Are any of your employees "economically disadvantaged?"
Yes
No
Total number of employees considered economically disadvantaged?
Rev/2/2009
Page 25
application.
APPLICATION FOR
Please complete the following for all economically disadvantaged employees. Attach Appendix D for
each employee as well.
Employee Name
Trade/Job Title
Date Hired
MWLBE PROGRAMS
Do you want to be certified by the SCA?
Yes
No
Complete this section only if you answered "Yes" to the previous question.
Which certification(s) would you like to request?
MBE
WBE
Is the Applicant Firm interested in applying to the SCA's Mentor Program?
LBE
Yes
No
Has the firm applied for or received a determination for certification as an M/WBE with another
government agency, department or authority?
Yes
Rev/2/2009
No
Page 26
application.
APPLICATION FOR
Agency
Contact Person Name and
Phone # (not toll-free)
Date
MWLBE Status
Please attach a copy of each certification.
Are there appeals pending on any of the above applications or certifications?
Yes
No
Agency
Date of Appeal
Contact Person Name and
Phone # (not toll-free)
Has the Applicant Firm ever been denied or had its application for certification for any of the preceding
designations rejected?
Note: Matters under appeal must be disclosed.
Yes
No
Has the Applicant Firm ever had its certification rescinded?
Note: Matters under appeal must be disclosed.
Yes
No
How did you hear about the SCA MWLBE certification program?
SCA website
Outreach event
Please specify name of event and date:
Advertisement
Please specify where:
Word of mouth
Please specify who:
Other
Please provide details:
Rev/2/2009
Page 27
application.
APPLICATION FOR
THIS DOCUMENT WAS PREPARED BY
Name:
Title:
Date:
Rev/2/2009
Page 28
application.
APPLICATION FOR
APPENDIX A
CERTIFICATION TO APPLICATION FOR PREQUALIFICATION AND/OR MWLBE CERTIFICATION
This Certification must be completed by each current Key Person of the Applicant Firm. Certifications must be signed before a
notary public and notarized when signed.
A MATERIAL FALSE STATEMENT OR OMISSION MADE IN CONNECTION WITH THIS APPLICATION MAY RESULT IN
THE DENIAL OF THE APPLICATION OR REVOCATION OF THE APPLICANT FIRM’S EXISTING STATUS AS A
PREQUALIFIED AND/OR MWLBE CERTIFIED BIDDER,RESULTING IN THE DISQUALIFICATION OF THE APPLICANT
FIRM. UNDER THE NYCSCA’S GUIDELINES, SUCH DISQUALIFICATION MAY PRECLUDE THE APPLICANT FIRM
FROM DOING BUSINESS WITH, OR PERFORMING WORK FOR, THE NYCSCA IN ANY CAPACITY. IN ADDITION,
SUCH FALSE SUBMISSION MAY SUBJECT THE PERSON AND/OR ENTITY MAKING THE FALSE STATEMENT TO
CRIMINAL CHARGES, INCLUDING NEW YORK STATE PENAL LAW SECTIONS 175.35 (OFFERING A FALSE
STATEMENT FOR FILING) AND 210.40 (SWORN FALSE STATEMENT) AND/OR TITLE 18 U.S.C. CRIMES, INCLUDING
FALSE OR FRAUDULENT STATEMENT, AND MAIL AND/OR WIRE FRAUD.
I,
(Full Name)
am
(Title)
being duly sworn, under penalties of perjury, hereby state that I
of
(Name of Applicant Firm)
,
the Applicant Firm that is applying for Prequalification and/or MWLBE Certification status with the NYCSCA. I have read and
understand the questions contained in the Application and all its appendices (“the Application”).
I have personally reviewed all questions and answers in the submitted Application and certify that, to the best of my
knowledge, the information and responses to all questions in the Application are full, complete, and truthful.
I agree and warrant that truthfully answering these questions is an event entirely within my control.
I acknowledge that the NYCSCA may, by means it deems appropriate, determine the accuracy and truthfulness of the
statements made in the Application.
I authorize the NYCSCA to contact any entity or individual named in the Application for the purpose of verifying the
information supplied by the Applicant Firm.
I recognize that all the information submitted is provided for the express purpose of inducing the NYCSCA to qualify the
Applicant Firm as a prequalified bidder, and/or certify the applicant as MWLBE-certified, award a contract, and/or allow the
Applicant Firm to participate in NYCSCA projects as a contractor, subcontractor, vendor, supplier, or consultant .
I understand and agree that the Application, once certified as accurate and submitted to the NYCSCA, may not be withdrawn
by the Applicant Firm without the express written permission of the NYCSCA.
You must submit in writing to the NYCSCA any substantive changes to your prequalification application as soon as
possible, but no later than (30) days of said change(s). Substantive changes include, but not limited to, key people,
ownership, court proceedings, investigations, bankruptcies, etc.
“Application” as used herein shall mean the original application for prequalification and/or MWLBE certification filed with the
NYCSCA, and any subsequent submissions, filings, updates, attachments or amendments thereto submitted to or filed with
the NYCSCA in writing or electronically, as of the date of the signature on this Appendix A.
State of __________________ )
County of __________________ )
Sworn to before me
this ____ day of __________, 201
Notary Public
Rev/01/30/2013
________________________________/___________
Name (print)
Date
________________________________/___________
Signature
Title
Page 29
application.
APPLICATION FOR
APPENDIX B MASTER FORMAT CODES
00000
01400
01450
01530
02000
02110
02115
02120
02145
02170
02195
02200
02210
02220
02240
02250
02260
02300
02390
02400
02450
02500
02510
02550
02600
02620
02660
02700
02800
02820
02882
02900
03000
03100
03150
03200
03300
03390
03400
03500
03600
03700
03900
04000
04060
04090
04200
04400
04500
04600
04900
05000
05060
05080
05090
05100
05120
05200
05300
05400
UNDETERMINED
QUALITY REQUIREMENTS
QUAL. CNTRL/FLD SMPl/TEST & INSP SRVC
TEMP CONSTR/BRDGS/DECK/OVERPASS
ALL DIVISION 2 - SITEWORK
REMOVAL OF TOXIC/HAZ SITE MTRLS
UNDERGROUND STORAGE TANK RMVL
OFF-SITE TRANSPORT & DISPOSAL
GROUNDWATER TREATMENT SYSTEMS
COFFERDAMS
REMEDIATION SOIL STABILIZATION
SITE PREPARATION
SUBSURFACE INVESTIGATION
DEMOLITION
DEWATERING
SHORING AND UNDERPINNING
EXCAVATION SUPPORT SYS/COFFERDAMS
EARTHWORK
MARINE WORK
TUNNELING
PILES AND CAISSONS
PIPED UTILITY MATERIALS
WATER DISTRIBUTION
FUEL DISTRIBUTION
SEWERAGE AND DRAINAGE
RESTORATION OF UNDRGRD PIPELINES
PONDS AND RESERVOIRS
PAVING AND SURFACING
SITE IMPROVEMENTS
FENCES AND GATES
SPORTS FIELDS, PLAY FIELDS
LANDSCAPING
ALL DIVISION 3 - CONCRETE
CONCRETE FORMWORK
CONCRETE ACCESSORIES
CONCRETE REINFORCEMENT
CAST-IN PLACE CONCRETE
CONCRETE CURING
PRECAST CONCRETE
CEMENTITIOUS
GROUT
MASS CONCRETE
CONCRETE RESTORATION/CLEANING
ALL DIVISION 4 - MASONRY
MORTAR
MASONRY ACCESSORIES
UNIT MASONRY
STONE
REFRACTORIES
CORROSION RESIST MASONRY
MASONRY RESTORATION/CLEANING
ALL DIVISION 5 - METALS
METAL MATERIALS
METAL FINISHES
METAL FASTENING
STRUCTURAL METAL FRAME
STRUCTURAL STEEL
METAL JOISTS
METAL DECKING
COLD-FORMED METAL FRAMING
Rev/7/1/2014
05500
05580
05600
05650
05700
05800
06000
06050
06070
06100
06130
06170
06200
06400
06500
06600
07000
07100
07110
07180
07200
07300
07400
07410
07500
07600
07700
07800
07810
07840
07900
08000
08100
08200
08250
08300
08400
08500
08550
08580
08600
08700
08770
08800
08900
09000
09100
09200
09250
09300
09400
09510
09545
09600
09610
09620
09630
09640
09650
METAL FABRICATIONS
SHEET METAL FABRICATION
HYDRAULIC STRUCTURES
RAILROAD WORK
ORNAMENTAL METAL
EXPANSION CONTROL
ALL DIVISION 6 - WOOD AND PLASTICS
FASTENERS AND ADHESIVES
WOOD TREATMENT
ROUGH CARPENTRY
HEAVY TIMBER CONSTRUCTION
PREFABRICATED WOOD/METAL JOISTS
FINISH CARPENTRY
ARCHITECTURAL WOODWORK
PREFAB STRUCTURAL PLASTIC
PLASTIC FABRICATIONS
ALL DIVISION 7 - THERMAL/MOIST PROTECT
WATERPROOFING
DAMPPROOFING
TRAFFIC TOPPING
THERMAL INSULN - VAPOR/AIR RETARDERS
SHINGLES AND ROOFING TILES
PREFORMED ROOFING & CLADDING/SIDING
METAL ROOFS AND WALL PANELS
MEMBRANE ROOFING
FLASHING AND SHEET METAL
ROOF SPECIALTIES/ACCESSORIES
FIRE & SMOKE PROTECTION
SPRAY-ON FIREPROOFING
FIRESTOPPING
JOINT SEALERS
ALL DIVISION 8 - DOORS AND WINDOWS
METAL DOORS AND FRAMES
WOOD AND PLASTIC DOORS
DOOR OPENING ASSEMBLIES
SPECIAL DOORS
ENTRANCES AND STOREFRONTS
METAL WINDOWS
WOOD AND PLASTIC WINDOWS
SPECIAL WINDOWS
SKYLIGHTS
HARDWARE
INSTALLATION: WINDOW GUARDS
GLAZING
GLAZED CURTAIN WALLS
ALL DIVISION 9 - FINISHES
METAL SUPPORT AND FRAMES
LATH AND PLASTER
GYPSUM BOARD
TILE
TERRAZZO
ACOUSTICAL TREATMENT
SPECIAL SURFACES
STONE FLOORING
FLOOR TREATMENT
SPECIAL FLOORING
UNIT MASONRY FLOORING
WOOD FLOORING
RESILIENT FLOORING
Page 30
application.
APPLICATION FOR
09680
09700
09770
09800
09900
10000
10100
10150
10200
10240
10250
10260
10270
10290
10300
10340
10350
10400
10450
10500
10520
10530
10550
10600
10650
10670
10700
10750
10800
10880
10900
10950
11000
11010
11020
11030
11040
11050
11060
11070
11080
11090
11100
11110
11120
11130
11140
11150
11160
11170
11190
11200
11280
11300
11400
11450
11460
11470
11480
11500
11600
11650
11660
11680
CARPET
WALL COVERING
AGGREGATE COATINGS/WALL FINISH
SPECIAL COATINGS
PAINTING
ALL DIVISION 10 - SPECIALTIES
CHALKBOARDS/TACKBOARDS
COMPARTMENTS AND CUBICLES
LOUVERS AND VENTS
GRILLES AND SCREENS
SERVICE WALL SYSTEMS
WALL AND COVER GUARDS
ACCESS FLOORING
PEST CONTROL
FIREPLACES AND STOVES
PREFAB EXTERIOR SPECIALTY
FLAGPOLES
IDENTIFYING DEVICES
PEDESTRIAN CONTROL DEVICES
LOCKERS
FIRE PROTECTION SPECIALTIES
PROTECTIVE COVERS
POSTAL SPECIALTIES
PARTITIONS
OPERABLE PARTITIONS
STORAGE SHELVING
EXTERIOR SUN CONTROL DEVICES
TELEPHONE SPECIALTIES
TOILET/BATH ACCESSORIES
SCALES
WARDROBE/CLOSET SPECIALTY
FALL PROTECTION SYSTEMS
ALL DIVISION 11 - EQUIPMENT
MAINTENANCE EQUIPMENT
SECURITY/VAULT EQUIPMENT
TELLER/SERVICE EQUIPMENT
ECCLESIASTICAL EQUIPMENT
LIBRARY EQUIPMENT
THEATER/STAGE EQUIPMENT
INSTRUMENTAL EQUIPMENT
REGISTRATION EQUIPMENT
CHECKROOM EQUIPMENT
MERCANTILE EQUIPMENT
COMMERCIAL LAUNDRY/DRY CLEAN
VENDING EQUIPMENT
AUDIO-VISUAL EQUIPMENT
VEHICLE SERVICE EQUIPMENT
PARKING CONTROL EQUIPMENT
LOADING DOCK EQUIPMENT
SOLID WASTE HANDLING EQUIP
DETENTION EQUIPMENT
WATER SUPPLY/TREATMENT
HYDRAULIC GATES/VALVES
FLUID WASTE DISPOSAL EQUIPMENT
FOOD SERVICE EQUIPMENT
RESIDENTIAL EQUIPMENT
UNIT KITCHENS
DARKROOM EQUIPMENT
ATHLT/RECREAT/THERAP EQUIPMENT
INDUSTRIAL/PROCESS EQUIPMENT
LABORATORY EQUIPMENT
PLANETARIUM EQUIPMENT
OBSERVATORY EQUIPMENT
OFFICE EQUIPMENT
Rev/7/1/2014
11700
11780
11850
12000
12050
12100
12300
12400
12480
12490
12600
12800
13000
13010
13020
13030
13080
13090
13100
13120
13150
13175
13185
13190
13200
13220
13230
13240
13260
13280
13285
13290
13400
13500
13550
13600
13660
13700
13800
13850
13900
14000
14100
14200
14300
14400
14440
14500
14600
14700
14800
14900
15000
15050
15080
15180
15190
15230
15300
15400
15500
15530
15600
15700
MEDICAL EQUIPMENT
MORTUARY EQUIPMENT
NAVIGATION EQUIPMENT
ALL DIVISION 12 - FURNISHINGS
FABRICS
ARTWORK
MANUFACTURED CASEWORK
FURNITURE AND ACCESSORIES
RUGS AND MATS
WINDOW TREATMENT
MULTIPLE SEATING
INTERIOR PLANTS AND PLANTERS
ALL DIVISION 13 - SPECIAL CONSTRUCTION
AIR SUPPORTED STRUCTURES
INTEGRATED ASSEMBLIES
SPECIAL PURPOSE ROOMS
SOUND/VIBRATION/SEISMIC CONTROL
RADIATION PROTECTION
LIGHTNING PROTECTION
PRE-ENGRD STRUCT/SPCLTY MODULES
POOLS
ICE RINKS
KENNELS/ANIMAL SHELTER
SITE-CONSTRUCTED INCINERATORS
LIQUID/GAS STORAGE TANKS
FILTER UNDERDRAINS/MEDIA
DIGESTION TANK COVERS & APPURT
OXYGENATION SYSTEMS
SLUDGE CONDITION SYSTEM
HAZMAT REMED - LEAD PAINT REMOVAL
HAZMAT REMED - ASBESTOS ABTMNT & REM
HAZMAT REMED - MICROBIAL REMED
MEASUREMENT & CONTROL INSTR
RECORDING - INDUSTRIAL INSTR
TRANSPORTATION CONTROL INSTR
SOLAR ENERGY SYSTEMS
WIND ENERGY SYSTEMS
SECURITY ACCESS AND SURVEILLANCE
BUILDING AUTOMATION SYS & CNTRLS
DETECTION & ALARM
FIRE SUPPRESSION/SUPERV SYSTEMS
ALL DIVISION 14 - CONVEYING SYSTEMS
DUMBWAITER
ELEVATORS
MOVING STAIRS AND WALKS
LIFTS
SIDEWALK LIFTS
MATERIAL HANDLING SYSTEM
HOIST AND CRANES
TURNTABLES
SCAFFOLDING
TRANSPORTATION
ALL DIVISION 15 - MECHANICAL
BASIC MECHANICAL MATS/METHODS
MECHANICAL INSULATION
HEATING & COOLING PIPING (STEAMFITTING)
FUEL PIPING
LUBRICATING OIL SYSTEMS
FIRE PROTECTION
PLUMBING
HEAT GENERATION
ELECTRIC RESISTANCE HEATING
REFRIGERATION
HEATING, VENTIL & AIR CONDITION
Page 31
application.
APPLICATION FOR
15780
HEAT TRANSFER/ENERGY RECOVERY
15800
AIR DISTRIBUTION/DUCTWORK
15810
DUCT CLEANING
15850
AIR HANDLING
15900
CONTROLS
15950
TESTING/ADJUSTING/BALANCE
16000
ALL DIVISION 16 - ELECTRICAL
16050
BASIC ELECTRICAL MATERIALS/METHODS
16080
ELECTRICAL TESTING
16100
WIRING METHODS
16200
POWER GENERATION
16300
HIGH VOLTAGE DISTRIBUTION - 600V+
16400
SERVICE/DISTRIBUTION - 600V & LESS
16500
LIGHTING
16550
SPECIAL SYSTEMS
16700
COMMUNICATIONS
16710
COMMUNICATION CIRCUITS
16800
SOUND AND VIDEO (TV STUDIOS)
16810
SURVEILLANCE CAMERAS/CAT 5/CAT 6
20019
SPEC - PLUMBING & DRAINAGE LARGE
ARCH/ENGR/CM/CRS
31000
ARCH - MODIFICATION/SPECIAL ENHANCEMENTS
31005
ARCH - NEW CONSTR/ADDITIONS/MINI-SCHOOLS
31010
ARCH - OTHER SPCLTS (USE WITH PROFILE CODES)
31015
ARCHITECTURAL - FULL SERVICE FIRM
32000
ENGR - MODIFICATION/SPECIAL ENHANCEMENTS
32005
ENGR - NEW CONSTR/ADDITIONS/MINI-SCHOOLS
32010
ENGINEERING - ELECTRICAL
32015
ENGINEERING - MECHANICAL
32020
ENGINEERING - PLUMBING
32025
ENGINEERING - M/E/P FULL SERVICE FIRM
32030
ENGINEERING - CIVIL/STRUCTURAL
32035
ENGR - OTHER SPCLTS (USE WITH PROFILE CODES)
32040
ENGR-FULL SERVIC
33000
ARCH & ENG - FULL SERVICE FIRM
34000
ARCH & ENG - UNCLASSIFIED
35000
CONSTRUCTION MANAGERS
36000
CONSTR RELATED SRVCS (USE W/PROFILE CODES)
37000
TOPOGRAPHICAL MAPPING
PROFILE CODES
37001
ACOUSTICAL/NOISE ABATEMENT
37002
ADA COMPLIANCE
37004
AIR POLLUTION CONTROL
37005
ASBESTOS INSPECTION
37006
ASBESTOS MNGMNT PLANNER/DESIGN
37008
AUDITORIUMS/THEATRES
37009
AUTOMATION: CNTRLS/INSTR/ENERGY MGMT SYS
37011
BOILER/ENERGY
37015
BUILDING CODES/STANDARDS/ORDINANCES
37018
COMM SYSTEMS: TV/MICROWAVE/TELEPHONE
37019
COMPUTER FACILITIES/COMPUTER SERVICE
37020
Computer Aided Design & Drafting (CADD)
37021
CONSTRUCTION MANAGEMENT
37022
CONTROLLED INSPECTION
37023
COST ESTIMATING
37029
EDUCATIONAL FACILITIES/CLASSROOMS
37031
ELEVATORS/ESCALATORS/PEOPLE-MOVERS
37032
ENERGY CONSERVATION/NEW ENERGY SOURCES
37033
ENVMNTL IMPACT STUDIES/ASSESS/STMNTS
37034
EXTERIOR RESTORATION
37035
FIELD HOUSES/GYMS/STADIUMS
37036
FIRE PROTECTION
37037
FORENSIC ENGINEERING
37041
GRAPHIC DESIGN/SIGNAGE
Rev/7/1/2014
37043
HEATING/VENTILATION/AIR CONDITIONING
37047
HISTORICAL PRESERVATION
37055
INTERIOR DESIGN
37056
IRRIGATION/DRAINAGE
37057
KITCHENS
37059
LANDSCAPE ARCHITECTURE
37060
LIBRARIES
37061
LIGHTING (Interior)
37062
LIGHTING (Exterior)
37069
MODLR SYS DESIGN/PREFABRICATED STRUCTURES
37078
PLANNING - COMMUNITY/ZONING
37079
PLANNING - SITE/PROJECT/SPACE
37080
PLUMBING/PIPING DESIGN
37081
PNEUMATIC STRCTR/AIR-SUPPORT BUILDINGS
37088
RECREATIONAL FACILITIES (Parks, Playgrounds)
37089
REHABILITATION - BLDNG/STRCTR/FACILITIES
37090
ROOFING CONSULTANTS
37093
SAFETY ENG/ACCIDENT STUDIES/OSHA STUDIES
37094
SECURITY SYS/INTRUDER & SMOKE DETECTION
37095
SEISMIC DESIGNS AND STUDIES
37096
SHOP EQUIPMENT
37097
SOILS AND GEOLOGICAL STUDIES/FOUNDATIONS
37102
SURVEYING
37103
SWIMMING POOLS
37106
TESTING/INSPECTION SERVICES
37107
TRAFFIC/TRANSPORTATION ENGINEERING
37111
UTILITIES (Gas/Steam)
37112
VALUE ENGINEERING/ANALYSIS
37115
WATER SUPPLY - TREATMENT AND DISTRIBUTION
37117
ZONING/LAND USE STUDIES
VENDOR/SUPPLIER CODES
80000
ALARM/SECURITY SYSTEMS
80005
ATHLETIC EQUIPMENT
80010
AUDIO/VISUAL EQUIPMENT
80015
AUTOMOBILES
80020
BUSES
80025
CLEANING/MAINTENANCE
80030
COMPUTER HARDWARE
80035
COMPUTER MAINTENANCE
80040
COMPUTER SOFTWARE
80045
COPIER SUPPLIES
80050
COPIERS
80055
DATA ENTRY
80060
DECORATIVE ACCESSORIES
80065
DELIVERY SERVICES (COURIER)
80070
ELECTRICAL SUPPLIES
80075
ELECTRONIC EQUIPMENT
80080
EQUIPMENT
80085
EQUIPMENT LEASING (RENTALS)
80090
FENCES
80095
FLOORING
80100
FOOD
80105
FOOD SERVICE
80110
FURNISHINGS
80115
FURNITURE DESIGN
80120
HVAC EQUIPMENT
80125
KITCHEN EQUIPMENT
80130
LANDSCAPE EQUIPMENT
80135
LIBRARY FURNITURE
80140
LITERATURE DESIGN
80145
LOCKERS/LOCKER EQUIPMENT
80150
MAIL/POSTAGE
80155
MEMBERSHIP/SUBSCRIPTIONS/LICENSE FEES
80160
MICRO-FILM/FICHE SERVICES
Page 32
application.
APPLICATION FOR
80165
MOVING
80175
N.Y.S. INDUST. FOR HANDICAPPED
OFFICE EQUIPMENT (MAINTENANCE-REPAIR)
80180
OFFICE FURNITURE
80185
OFFICE SUPPLIES
80190
OFFSET
80195
PARKING
80198
PHOTOGRAPHIC SERVICES
80200
PRINTING
80205
PUBLICATIONS
80210
RECORDS MANAGEMENT SYSTEM
80215
REFUSE/WASTE EQUIPMENT
80220
REPROGRAPHICS
80225
RUBBISH REMOVAL
80230
SAFETY EQUIPMENT
80235
SHELVING/COMPARTMENTS
80240
SHOP EQUIPMENT
80245
SIGNAGE
80250
SUPPLIES
80255
TELECOMMUNICATION EQUIPMENT
80260
TEXTBOOKS
80265
TRAILERS
80270
TRANSPORTATION
80275
TRUCKS
80280
VEHICLE MAINTENANCE/TOWING
80285
VIDEO DUPLICATION
80290
WINDOW EQUIPMENT
80295
METAL ROOFING SYSTEMS
80300
SERVICES
83000
WINDOW EQUIPMENT
84012
PROFESSIONAL SERVICE PROVIDER CODES
86000
ACCOUNTANTS/AUDITORS
ADVERTISING
86005
PROFESSIONAL SERVICES - NON CONSTRUCTION
86009
ATTORNEYS/LEGAL SERVICES/LAWYERS
86010
BUSINESS SYSTEMS
86015
COMPUTER - HARDWARE/SOFTWARE
86020
COMPUTER DESIGN & DEVELOPMENT
86025
ENVIRONMENTAL CONSULTING SERVICES
86030
ASBESTOS CONSULTANTS
86031
LEAD CONSULTANTS
86032
MOLD CONSULTANTS
86033
HAZMAT-UST, CONFINED SPACES, SOIL/GROUND
86034
SPILL RESPONSE, GEOSCIENCE/GEOLOGY
86035
FINANCIAL SERVICES
86040
INFORMATION TECHNOLOGY CONSULTANT
INSURANCE
86045
INVESTIGATION/IPSIG
86050
MANAGEMENT CONSULTANT
86055
PERSONNEL SERVICES - TEMPORARY
86060
PUBLISHING/EDITING/GRAPHIC DESIGN
86065
86070
REALTOR/REAL ESTATE/APPRAISER
86075
RECRUITERS
86080
SECURITY SERVICES - WATCHGUARD/PATROL
86085
SITE SAFETY MANAGER
86090
TRAINING SERVICES (SUPPORT)
86095
TRAVEL/TRAVEL AGENT
86100
CONSULTANT-OTHER
GENERAL CONTRACTORS
99915
GENL CONTR - HISTORICAL RESTORATION
99930
GENL CONTR - LINE PROJECTS
99945
GENL CONTR - EXTERIOR MODIFICATIONS
99960
GENL CONTR - INTERIOR MODIFICATIONS
99999
GENERAL CONTRACTOR
x
Rev/7/1/2014
Page 33
application.
APPLICATION FOR
APPENDIX C
BONDING LETTER SAMPLE
__________________________ , 20___
Re:
Dear :
We hereby confirm that
, ("Contractor"), is a highly valued client of
Insurance Company.
We hereby confirm that the "Contractor" has a surety program of $ million single/$ million aggregate. We estimate the
current available bonding capacity is
$ million.
Please be advised that all requests for performance and payment bonds are subject to the review and acceptance of the
terms and conditions of the contract by the Surety Company and satisfactory evidence of financing for the job, and the
normal underwriting review by the surety at the time of the request of the bonds. This letter merely renders an opinion and
does not constitute a bid bond or consent of surety. We assume no liability to you or to third parties if for any reason the
"Contractor's" Surety Company declines to issue the bond.
Please feel free to call me with any questions. By this letter our client has authorized us to respond to any questions the
SCA has.
Rev/2/2009
Page 34
application.
APPLICATION FOR
APPENDIX D
VERIFICATION OF ECONOMICALLY DISADVANTAGED STATUS
The "Verification of Economically Disadvantaged Status" form should be completed by each employee you are claiming
as an "economically disadvantaged person". The employee filling out this form only needs to complete the appropriate
section below. A person may be considered "economically disadvantaged" because of his income, or his or her status
as a Vietnam era veteran, or his or her status as a displaced homemaker. Attach additional copies of these pages for
each "economically disadvantaged" employee as necessary.
1. Name of Employee
2. Social Security Number
3. Income of Eligibility
3a. Were you (if living alone), or your household, receiving welfare or public assistance? Yes
dates: FROM ___________ TO _____________
No
If "Yes", give
3b. Indicate the total number of persons in your household
3c. Indicate below the income of each person living in your household for the tax year ending 20
.
Name of household member (1)
Relationship to you
Income $
Relationship to you
Income $
Relationship to you
Income $
Relationship to you
Income $
3d. Total Household Income $
Rev/2/2009
Page 35
application.
APPLICATION FOR
APPENDIX E(3)
Prequalification and Minority/Woman/Locally Based Business Enterprise (M/W/LBE) Certification
DOCUMENT CHECKLIST AND INSTRUCTIONS
Prequalification Application
NEW YORK STATE, DIVISION OF CORPORATIONS
Please check the New York State, Division of Corporations website to determine if your firm is deemed active in the State of
New York. Visit www.dos.state.ny.us and click on Search the Corporations/Business Entities Database. Do not proceed with your
application if your firm is not in an active status.
NEW YORK STATE AGENCY DEBARMENT LIST
Before starting your firm’s qualification application, check the New York State Agency Debarment List at
https://dbr.labor.state.ny.us/EDList/searchPage.do.




Check both the WCB and DOL boxes.
Without using a hyphen, enter your firm’s Federal Employer ID#.
If your firm appears on the NYS Department of Labor and/or NYS Workers Compensation Board list, do not proceed with your
prequalification application.
Call the NYS Workers Compensation Board at 1-866-546-9322 and/or NYS Department of Labor at 518-457-9000 for further
information.
DOCUMENT CHECKLIST
To make the prequalification process as smooth and easy as possible, you should gather together and have with you the following
information when you fill out the application (online or handwritten):
CATEGORY
Financial
Statements
and Tax
Returns
Rev/7/2/2013
EXPLANATION
REQUIRED DOCUMENTATION/INFORMATION
All Applicant Firms, regardless of type and/or
dollar amount.
If the Applicant Firm conducted business within the City of New York, a copy of the firm's
most recent New York City General Corporation tax return or New York City Unincorporated
Business tax return must be provided.
The tax return must be signed and dated by both the preparer and the Firm's designated
officer. If not applicable, attach a statement from the Applicant Firm’s CPA or tax preparer
stating the reason(s) why a NYC business tax return is not required.
Page 36
application.
APPLICATION FOR
CATEGORY
EXPLANATION
Trade contractors seeking prequalification for
dollar amounts ≥$1,000,000, as well as
general contractors and construction
managers, regardless of dollar amount.
Copy of the Applicant Firm's two most recent "audited" financial statements including the
Certified Public Accountant's signed report, balance sheet, statements of income and
retained earnings, statement of cash flow and footnotes.
OR
Copy of the Applicant Firm's two most recent "reviewed" or "compiled" financial statements
and the two most recent Federal tax returns (including all supporting schedules), which must
be signed and dated by both the preparer and the Firm's designated officer. If the returns
were filed electronically, a copy of IRS Form 8879 (IRS e-file Signature Authorization) signed
by both an officer of the Applicant Firm and the preparer will be valid evidence of signature;
however, a copy of the entire Federal tax return must still be provided.
If the Applicant Firm is a Sole Proprietorship or Single Member LLC treated as a disregarded
entity for federal tax purposes, submit two (2) years of the Federal Schedule C from the
owner’s personal tax return.
Resumes
Licenses
Safety
Qualification
Statement
Supporting
Documents
Matters Under
Appeal
Rev/7/2/2013
All officers, partners, owners, members,
managers, supervisors, field personnel or
professionals with experience in the fields for
which the Applicant Firm is requesting
prequalification.
All architects, engineers, electricians,
plumbers, asbestos inspectors/ handlers and
all firms that require licenses to perform work.
If the Applicant Firm does not have audited, reviewed or compiled financial statements,
provide full Federal tax returns with signatures.
Current resume – must include home address, telephone number, education, training and
employment history with dates.
Copy of current license, license registration, certificate, or certification.
Companies engaging in the removal of regular waste, recyclable materials, and
construction/demolition debris must, in addition to a prequalification application, provide a
copy of its license/registration from the NYC Business Integrity Commission. For more
information, visit www.nyc.gov/html/bic.
Applicant Firm.
 Letter from Applicant Firm’s insurance carrier stating its most recent Experience
Modification Rating (EMR).
 Copy of Applicant Firm’s OSHA 300 and 300A logs for the most recent calendar year.
All architects, engineers, testing laboratories,  Completed Qualification Statement. (For architectural and engineering firms, a copy of the
and firms specializing in asbestos or
Form 330 is acceptable in lieu of the Qualification Statement).
environmental work.
 Copy of the Applicant Firm's brochure, if available.
For any questions to which you answer “yes,” Supporting documentation.
including all satisfied suits, tax liens or
warrants, repayment plans, judgments,
litigation or court actions detailed in the
Application.
Information regarding any pending suits,
Supporting documentation.
liens, judgments, litigation, violations,
investigations, criminal or administrative/court Investigation – Includes (a) an appearance before a grand jury by any representative of the
actions, and civil investigative demands.
Applicant Firm or its affiliate firm(s) or any Key Person; (b) the issuance of a subpoena to the
Applicant Firm or its affiliate firm(s) or any Key Person for the giving of testimony or the
production of documents in a criminal proceeding or before a government or public agency,
permanent or temporary commission or an investigative body; (c) the execution of a search
warrant at any location occupied by the Applicant Firm or affiliate firm(s) or any Key Person;
(d) the questioning of an employee by a government or public agency, permanent or
temporary commission or an investigative body, including a court appointed monitor
concerning the business conduct of the Applicant Firm or the affiliate firm(s); (e) receipt of
any discovery demand in a civil or regulatory matter in connection with an inquiry by or in
which any government or public agency, permanent or temporary commission or an
investigative body is a party.
Page 37
application.
APPLICATION FOR
CATEGORY
EXPLANATION
Affiliate Firms
Affiliate firm information; includes firms listed in the Business Organization & History section,
and Key People in the Key People & Personnel section, within the timeframes indicated.
Include tax identification number of all affiliate firms and name of key person associated with
that particular affiliate. Include ownership timeframe.
-
-
References
Firms the Applicant Firm has
owned 5% or more of,
Firms that own 5% or more of the
applicant firm.
Firms that are a subsidiary of
the Applicant Firm.
Firms where the Key People of
Applicant Firm have served as Key
People or owned 5% or more of any
other firm, including firms that are
inactive, have been dissolved or are
non-construction related.
Firms that share offices, warehouses,
space, equipment, staff or telephone
exchanges.
For trades in which the Applicant Firm seeks
qualification.
-
-
Experience
For qualification >$1,000,000 per contract, the Applicant Firm must provide a minimum
of 4 commercial references per trade for which the firm wishes to be qualified,
completed within the past 3 years, averaging at least $1,000,000 and proof of
apprenticeship program participation, if applicable.
For qualification < $1,000,000 per contract, the Applicant Firm must provide a minimum
of 4 commercial references per trade for which the firm wishes to be qualified,
completed within the past 3 years; each reference must be ≥$25,000.
Includes, but not limited to, a minimum of 2 years in business and applicable references.
Corporate
Status
Your firm must be deemed active by the New
York State Division of Corporations.
Visit www.dos.state.ny.us and click on Search the Corporations/Business Entities Database.
Conflict of
Interest
Is any Key Person currently a New York City
Employee or has any Key Person been a
New York City employee within the past
year?
Conflicts of Interest Waiver must be provided.
Rev/7/2/2013
Page 38
application.
APPLICATION FOR
CATEGORY
EXPLANATION
Appendix A
(Certification)
Each Key Person of Applicant Firm.
Notarized certification (Appendix A); certifications must be signed before a notary public
and notarized when signed. Stamped signatures for either the notary public or key person
are not acceptable.
"Key People" include:








President, Chief Executive Officer, proprietor(s), principal(s), partners,
directors, officers, members.
Partners, including general, limited and limited liability.
Members – Admitted as members of a limited liability company (LLC), with
a membership interest in the LLC. Membership interest is a member's
aggregate rights in an LLC, including, without limitation, the member's right
to a share of the profits and losses of the LLC and the right to vote and
participate in the management of the LLC.
Corporations – Publicly held corporations should list the President,
Treasurer, Chief Financial Officer, shareholders of 5% or more of the firm's
issued stock, and only those officers and managers who will have direct
responsibility for SCA contracts. Shareholders are owners of 5% or more
of issued stock or other securities (stock options, secured or unsecured
bonds, warrants rights) that can be converted to stock that, if exercised,
would constitute 5% or more of the firm's issued stock.
Non-publicly held corporations should list all Corporate Officers and all
Shareholders (owners of 5% or more of authorized shares).
Any person in a position to control and direct the firm's overall operations
and financial decisions, including "hiring and firing."
Signatories to bank accounts and collective bargaining agreements,
whether or not considered "Key People."
Holders of licenses necessary for the Applicant Firm to perform SCA work
for which it is seeking Prequalification.
GENERAL INFORMATION
The New York City School Construction Authority (SCA) was created in 1988 by the New York State Legislature for the purpose of
constructing and renovating educational facilities throughout the five boroughs. The SCA enters into contracts with general contractors,
architects, engineers, trade contractors, consultants and other businesses. The SCA awards contracts to firms that are prequalified, with
the exception of vendor contracts valued under $10,000. All firms seeking prequalification must complete an application online.
Your completed application will be thoroughly reviewed and evaluated by the SCA, taking into consideration a variety of factors including,
but not limited to (and listed in no particular order):








1
Experience
Quality and timeliness of past performance
Financial capability (where applicable)
Reliability and responsibility
Safety record
Compliance with equal employment requirements including LBE (Local Business Enterprise), MBE (Minority Business
Enterprise) and WBE (Woman-owned Business Enterprise)
1
Enrollment in New York State Department of Labor-approved apprenticeship training programs for those trades in which an
2
applicant firm seeks prequalification
Integrity of the firm, its key people, affiliates, current and past owners, and principals
Only apprentices registered with the New York State Department of Labor pursuant to their registration and the law may be employed. The prevailing
wage Schedule 220 published by the Office of the Comptroller of the City of New York provides the rates and ratios applicable to registered
apprentices. For more information, visit the SCA’s website at www.nycsca.org.
2
The only exception to this requirement is for firms that participate exclusively in the SCA Mentor Program.
Rev/7/2/2013
Page 39
application.
APPLICATION FOR
Once an application is submitted, it cannot be withdrawn without the express written permission of the SCA.
The Applicant Firm and the Key People listed in this application make all statements and provide all information for the purpose of
inducing the SCA to grant prequalification status to the Applicant Firm.
This application will not be considered complete until it is signed by all of the Key People of the Applicant Firm, notarized, and the bar
coded Appendix A certification(s) received by the SCA.
You must submit in writing to the NYCSCA any substantive changes to your prequalification application as soon as possible,
but no later than (30) days of said change(s). Substantive changes include, but not limited to, key people, ownership, court
proceedings, investigations, bankruptcies, etc.
NOTE: Joint Venture applicants must submit a prequalification application for itself AND each Joint Venture partner.
INSTRUCTIONS
1.
This form should be completed on behalf of the Applicant Firm by an individual who is knowledgeable about the past and present
operations of the Firm and its policies.
2.
A response must be provided to each question on the application.
The SCA reserves the right to request additional information and/or documentation based on the answers provided to the
questions contained in the application.
The SCA will not evaluate the application form if any answers are missing or incomplete. Firms whose applications are
incomplete will be notified via email to provide ALL required information within 30 calendar days. Failure to respond within 30
days of this notice will result in the administrative closure of the application without further action. Effective the date of such
closure, the Applicant will not be approved for any work on SCA projects.
SUBMITTAL
Once you have completed all sections of the online application, click the Submit button to submit electronically.
APPENDIX A
Once you have submitted your application, be sure to follow the on-screen instructions to print out the bar coded Appendix A
(certification) and the bar coded fax cover sheet.




All current Key People of the Applicant Firm must file a bar coded, signed and notarized Appendix A.
The Appendix A document must be notarized when signed.
You may upload or fax a signed/notarized Appendix A.
After uploading or faxing the signed/notarized Appendix A document(s), mail the originals to:
30-30 Thomson Avenue
Long Island City, NY 11101
ATTN: Prequalification Unit
REQUALIFICATION
Firms are qualified for a period of three (3) years, after which they are required to validate/update their application information online.
Firms are strongly encouraged to submit for requalification at least six (6) months before their prequalification status expires.
Rev/7/2/2013
Page 40
application.
APPLICATION FOR
VENUE
Any dispute arising out of this Prequalification Application or relating to Prequalification in general, shall be heard and determined either
in the courts of the State of New York, located in the City of New York, County of New York ("New York State Courts"), or in the courts of
the United States located in New York City ("Federal Courts").
If an action or proceeding is commenced against the Authority in other than the above courts, and the Authority is forced to compel
compliance with this provision through motion practice, the Key People of the Applicant Firm shall be liable for all expenses, including
attorney's fees, incurred by the Authority in its effort to compel compliance.
GETTING HELP
Questions regarding the Prequalification Application should be directed to the Contractor Qualification Hotline at 718-472-8777.
You may visit the Contractor Qualification Unit Monday through Friday, between 9:00 a.m. and 4:00 p.m., for personal assistance with
the qualification process.
MWBE Certification is a review process designed to ensure that a business is actually owned, controlled,
and operated by the applicant(s). The requested documents are required for determining eligibility for
certification.
Applications will not be processed without required documentation or a written explanation.
Sole
Proprietor
Partnership
LLP
Joint
Venture
Corporation
LLC
Resumes for all principals, partners, officers and/or Key People. Must include home address, telephone
number, education, training and employment with dates.
X
X
X
Licenses and/or accreditations required to conduct business
X
X
X
Bank signature card, bank resolution, or letter from the bank identifying persons authorized to conduct
transactions, level of authority and limitations, if any
X
X
X
Current financial statement
X
X
X
Please submit prior three (3) years of your business’ Federal, State and City tax returns including all
schedules and w-2s where applicable. For businesses that are less than three years old, substitute three
(3) years of personal federal income tax returns including all schedules for each owner with an interest of
10% or more.
X
X
X
Proof of sources of capitalization/investments
X
X
X
Proof of ethnicity (e.g., birth certificate, U.S. passport, etc.)
X
X
X
Proof of U.S. citizenship (e.g., birth certificate, U.S. passport, naturalization certificate, etc.)
X
X
X
Proof of permanent resident alien status – i.e., permanent resident ("green") card
X
X
X
Copy of Lease Agreement
X
X
X
All third-party agreements including equipment rentals, purchase agreements, management service
agreements, etc.
X
X
X
Document(s) Required – MWBE
Rev/7/2/2013
Page 41
application.
APPLICATION FOR
Any employment agreements
X
X
X
Vehicle registration(s)
X
X
X
Any certification, decertification or denial of certification documentation
X
X
X
Written request for exemption from disclosure regarding trade secrets
X
X
X
Business Trade Name or Certification Trade Name filed with County Clerk (if doing business under an
assumed name)
X
Business Certificate
X
Certificate of Registration
X
Partnership Agreement
X
Buy-Out Rights
X
X
Articles of incorporation/organization, including date approved by NY State
X
Corporate by-laws/operating agreements
X
Minutes of first corporate organizational meeting and amendments
X
All issued stock certificates (front and back) and next unissued certificate
X
Stock ledger
X
If applicable, copies of agreements relating to:
X






Stock options
Shareholder agreements
Shareholder voting rights
Restriction on the disposal of stock loan agreements
Facts pertaining to the value of shares
Restriction on control of the corporation
DOCUMENTATION REQUIRED FOR LBE CERTIFICATION
LBE Certification is a review process designed to ensure that firms, regardless of the gender or ethnicity of
the owner, doing business in economically deprived areas of the City or employing economically
disadvantaged persons receive no less than 10% of subcontracting opportunities on construction and
construction-related contracts directly awarded by the SCA. *The requested documents are required for
determining eligibility for certification.
Additional Documents
Required – LBE
Explanation
Gross Receipts
Accountant's verification of gross receipts, including signature and license number.
Addresses
Provide addresses where Applicant Firm's jobs were performed during the previous calendar year.
Proof of Sole Proprietorship
(if applicable)
Business Certificate registered with County Clerk's office.
Rev/7/2/2013
Page 42
application.
APPLICATION FOR
Proof of Partnership (if
applicable)
Business Certificate registered with County Clerk's office.
Proof of Incorporation
Corporate filing receipt from NYS Department of State
Certification
Notarized certification; certifications must be notarized when signed. The notary may not be another Key Person in the Applicant Firm,
nor a relative of any Key Person signing a certification. The Appendix A certification form may be duplicated as needed.
GENERAL INFORMATION
The SCA MWBE (Minority, Women-Owned Based Enterprise) program provides opportunities for minority-owned, women-owned
enterprises to participate in the SCA's procurement process and gain valuable experience. To be eligible for the business development
opportunities that the SCA provides, a business must become M/WBE-certified in addition to being pre-qualified.
For each certification category, ownership must be real, substantial and continuing. The applicant must have and exercise the
authority to independently control the business decisions of the enterprise.
M/WBE INFORMATION


Minority Business Enterprise (MBE) – A business enterprise which is at least 51% owned by, and controlled or, in the case of
a publicly owned business, at least 51% of the stock of which is owned by citizens or permanent resident aliens; and whose
management and daily business operations are controlled by one or more such individuals meeting the ethnic definitions of
black, Hispanic, Asian-Pacific, Asian-Indian or Native American.
Women-Owned Business Enterprise (WBE) – A business enterprise which is at least 51% owned by, and controlled or, in the
case of a publicly owned business, at least 51% of the stock of which is owned by citizens or permanent resident aliens who are
women and whose management and daily business operations are controlled by women.
ETHNICITY DEFINITIONS
NAME
DEFINITION
Black
Persons having origins in any of the black African racial groups.
Hispanic
All persons of Mexican, Puerto Rican, Dominican, Cuban, Central or
South American descent of either Indian or Hispanic origin, regardless
of race. *Please note: Portuguese and Spanish ethnicities are not considered Hispanic for
M/WBE certification with the SCA.
Asian-Pacific
Persons having origins in the Far East, Southeast Asia or the Pacific
Islands.
Asian-Indian
Persons having origins in the Indian subcontinent.
Native
American
Persons having origins in any of the original peoples of North America.
Non-Minority
Persons whose culture or origin is other than those defined above.
LBE INFORMATION
Rev/7/2/2013
Page 43
application.
APPLICATION FOR




The Locally Based Enterprise Program was created in 1983 as a way of spurring economic development and creating jobs in
depressed communities. The goal of the program is to ensure that firms, regardless of gender or ethnicity, doing business in
economically deprived areas of the City or employing economically disadvantaged persons, receive not less than 10% of
construction and construction-related contracts awarded by this agency.
To participate in the Locally Based Enterprise Program of the New York City School Construction Authority (SCA), as outlined in
§6-108.1 of the New York City Administrative Code pursuant to Article 8, Title 6, §1743.2 of the Public Authorities Law and the
regulations promulgated thereunder, you must submit an application online or by mail.
If you are a proposed subcontractor on a pending contract, the application form should be filed with the NYC School Construction
Authority along with the applicable contractor's completed LBE Participation Schedule.
Definitions
o Locally-Based Enterprise (LBE) – A business which, at the time of application for certification, has been in the
general contracting business, the mechanical and electrical business or the specialty business and:
a. has been in business for more than one (1) tax year and has received gross receipts in the last three (3) or
fewer tax years averaging two million, one hundred sixty seven thousand dollars ($2,167,000) or less on an
annual basis; or
b. has been in business for less than one (1) tax year and has received gross receipts equal to or less than two
million, one hundred sixty seven thousand dollars ($2,167,000); and
c. in the tax year preceding the date of application has:
i.
earned at least twenty five percent (25%) of its gross receipts from work performed on construction
projects located in economic development areas; or
ii.
employed a work force of which at least twenty five percent (25%) were economically disadvantaged
persons.
o Economic Development Area – Areas of New York City designated as eligible for participation in the Community
Development Block Grant Program of the U.S. Department of Housing and Urban Development.
o Economically Disadvantaged Person – A person who, at the time of hiring by a Locally Based Enterprise, if such
hiring occurred not more than three years prior to the time of such business' application for certification or at the time
for such application, is:
d.
o
o
Rev/7/2/2013
a resident in a single person household who receives (i) wages not in excess of seventy percent of the lowerlevel "urban family budget" for the City as determined by the United States Department of Labor, Bureau of
Labor Statistics; or (ii) cash welfare payments under a federal, state or local welfare program; or
e. a member of a family which (i) has family income less than seventy percent of the lower-level "urban family
budget" for the City as determined by the United States Department of Labor, Bureau of Labor Statistics, or
(ii) receives cash welfare payments under a federal, state or local welfare program; or
f. a Vietnam era veteran as defined by applicable federal law who has been unable to obtain non-government
subsidized employment since being discharged from the armed forces; or
g. a displaced homemaker who has not been in the labor force for five years but has during those years worked
in the home providing unpaid services for family members and was (i) dependent on public assistance or the
income of another family member but is no longer supported by that income, or (ii) receiving public assistance
for dependent children in the home and that assistance will soon be terminated.
Gross Receipts – The total gross income received by an LBE applicant from any source during the applicable period.
The following table lists the income levels which are 70% of the "Lower Living Standard Income Level" for New York
City as determined by the U.S. Department of Labor, Bureau of Labor Statistics:
Page 44
application.
APPLICATION FOR
FAMILY SIZE LEVEL
LOWER LEVEL STANDARD INCOME
1
$ 11,022
2
$ 18,065
3
$ 24,797
4
$ 30,612
5
$ 36,122
6
$ 42,252
For family sizes above 6, add $4,020 for each additional family member.

Geographic Summary Of Work Performed – Firms must provide list of jobs on which the company worked within the low
income areas of the City of New York during the last complete tax year, whether or not these jobs were completed. Provide all
information requested for each of these jobs. If the owner of the job was a company or a government agency, provide the name
of a contact person and the contract number of the job. Be specific when giving the location of work performed (i.e.,
address, street, boundaries and boroughs), as this will be used as a criterion for eligibility in the LBE Program.
RECERTIFICATION
Firms are certified for a period of three (3) years, after which they are required to verify that there were no changes to the ownership (by
uploading or mailing a notarized affidavit) and provide tax returns for the last two years (online or by mail) Firms are strongly encouraged
to submit for recertification at least six (6) months before their certification status expires.
GETTING HELP
Questions regarding M/WBE certification should be directed to the Certification Hot Line at 718-472-8899.
You may visit the Business Development Division Monday through Friday, between 9:00 a.m. and 4:00 p.m., for personal assistance with
the certification process.
Rev/7/2/2013
Page 45

or Print Prequalification/ Certification Application.

Transcription

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