RD2.3 PREQUALIFICATION QUESTIONNAIRE, PASS/FAIL
(see [I]:4.3.2)

Each prospective bidder must have a current and active California contractor's license at the time of the bid opening and must submit this Prequalification Questionnaire with all portions completed, including any required attachments.

The undersigned declares under penalty of perjury that all of the prequalification information submitted with this form is true and correct and that this declaration was executed in ______________________ County, California, on ________________________ .

Each prospective bidder must answer all of the following questions and provide all requested information, where applicable. Any prospective bidder failing to do so may be deemed to be not responsive and not responsible with respect to this prequalification at the sole discretion of the University of California. All information submitted for prequalification evaluation will be considered official information acquired in confidence, and the University of California will maintain its confidentiality to the extent permitted by law. Any prospective bidder found to be not prequalified as a result of the bidder's answers to this Prequalification Questionnaire will receive written response from the University Facility explaining the Facility's decision. If the bidder can refute some of the facts upon which the decision was based, the bidder can request a hearing at the Facility to appeal the decision. The decision of the Facility is final and not appealable within the University of California.

1. License

1. Does your firm, including any partner if a joint venture, hold the following California contractor's license, which is current and in good standing with the California Contractor's State License Board?
   {LICENSE CLASSIFICATION}, {LICENSE CODE}

   YES ____ NO ______

   If yes, provide the following information about your firm's contractor's license:

   1. Name of license holder exactly as on file with the California Contractor's State License Board:
      __________________________________________________________________

   2. License classification: __________________________________________

   3. License code: __________________________________________

   4. License number: __________________________________________

   5. Date issued: __________________________________________

   6. Expiration date: __________________________________________

2. Has your firm's contractor's license ever been suspended or revoked by the California Contractor's State License Board?

   YES ____ NO ______

1. Has your firm, or any partner if a joint venture, completed {NUMBER} or more {TYPE} projects greater than ${ } since {DATE}?

   YES ____ NO ______

   If yes, provide the following information for such projects (repeat for each project for a maximum of {NUMBER} projects):

   1. Project name and location: ______________________________________________

   2. Name and telephone number of University: ______________________________________________

   3. Name and telephone number of design professional: ______________________________________

   4. Date construction contract was completed: ______________________________________________

   5. Contract amount: $ ________________

   6. Contract time: ________ days

   7. Number of days liquidated damages were assessed: _________ days

   8. Amount of liquidated damages assessed: $ _____________

   9. Did the project include {DESCRIBE ELEMENTS OF THE CONSTRUCTION THAT ARE NECESSARY TO DETERMINE THE EXPERIENCE REQUIRED TO SUCCESSFULLY PERFORM THE PROJECT WORK FOR WHICH PREQUALIFICATION IS SOUGHT}?

      YES ____ NO ______

   10. Percentage of work subcontracted: ________%

   11. Name of superintendent: ______________________________________________

3. Financial Data

1. Does your firm have ${ } of credit available to perform the work required under this construction contract?

   YES ____ NO ______

   If yes, provide a letter from each of your firm's banks or other lending institutions verifying the above amount of credit.

4. Safety

1. Is your firm's current workers' compensation Experience Modification Factor (EMF) less than {NUMBER}?

   YES ____ NO ______

   If yes, provide verification from your workers' compensation carrier.

2. Does your firm have a written Injury and Illness Prevention Program (IIPP) that complies with California Code of Regulations, Title 8, Sections 1509 and 3203?

   YES ____ NO ______

   If yes, provide a copy of the written program.

3. Will your firm have personnel permanently assigned to safety on this project?

   YES ____ NO ______

   If yes, state the names of all such personnel who will be assigned and individually list their specific duties (if necessary, list additional names in section 12):

   Name and Title	Specific Duties
   _______________________________	_______________________________
   _______________________________	_______________________________
   _______________________________	_______________________________
   _______________________________	_______________________________
   _______________________________	_______________________________
   _______________________________	_______________________________
   _______________________________	_______________________________

5. Claims History

1. Provide the following information on successful claims by University against your firm or by your firm against University since {DATE}. Include claims resolved by arbitration, or litigation. (Provide a sheet for each claim.)
   1. Project name and location: _______________________________________________________

   2. Name and telephone number of University: __________________________________________

   3. Contract amount: $ _______________

   4. Contract time: ______________days

   5. Nature of claim: _______________________________________________________

   6. Amount of claim in money and time: $ ______________, ______________days

   7. Final resolution of claim for your firm: $ ______________, ______________days

   8. Final resolution of claim against your firm: $ ______________, ______________days

6. Surety

1. Provide the following information on all sureties utilized since {DATE} (provide a sheet for each surety):
   1. Surety name and telephone number: _______________________________________________

   2. Period covered by surety: __________________ to __________________

   3. Maximum amount of bonding capacity provided by surety: $ __________________

   4. Number of construction contracts taken over by surety for completion: __________________

2. Provide the name and telephone number of the surety to be used on this construction contract:

   _______________________________________________

   _______________________________________________

   _______________________________________________

3. Is your firm able to obtain bonding in the amount of ${ } for this construction contract?

   YES ____ NO ______

   If yes, provide a notarized declaration from the surety listed in item 6.b. stating the amount of bonding capacity available to your firm for this construction contract.

7. Insurance

1. Is your firm able to obtain the following insurance in the limits stated?

   General liability: ${ } per occurrence ${ } in the aggregate.

   Business automobile liability: ${ }.

   YES ____ NO ______

   If yes, provide notarized declarations from your insurance carriers stating that your firm is able to obtain insurance in the limits stated above for this construction contract.

8. Affirmative Action

1. Does your firm have a written affirmative action program for employment?

   YES ____ NO ______

   If yes, provide a copy of the written program.

2. Does your firm have a written affirmative action program for the use of subcontractors and suppliers that are Small and Disadvantaged Business Enterprises (SDBEs), Small and Woman Business Enterprises (SWBEs), or Small and Disabled Veteran Business Enterprises (SDVBEs)?

   YES ____ NO ______

   If yes, provide a copy of the written program.

9. Staff Experience

1. Provide the following information on the person who will be in charge of this project:
   1. Name: _________________________________________________

   2. Years employed by your firm: __________________year(s)

   3. Present position/job function within your firm: _____________________________________

   4. Years in present position/job function: __________________ year(s)

1. Does your firm have a written quality assurance program?

   YES ____ NO ______

   If yes, provide a copy of the written program.

1. Has your firm ever been formally disqualified from performing work for the University of California?

   YES ____ NO ______

   If yes, provide the following information for each such disqualification:

   1. Facility: ______________________________________________________

   2. Project name: __________________________________________________

   3. Date of disqualification: __________________________________________

   4. Duration of disqualification: _______________________________________

   5. Reason for disqualification: _______________________________________

2. Has your firm ever been formally disqualified from performing work for any contracting entity other than the University of California?

   YES ____ NO ______

   If yes, provide the following information for each such disqualification:

   1. Name and telephone number of contracting entity: _______________________________________

   2. Project name: _______________________________________

   3. Date of disqualification: _______________________________________

   4. Duration of disqualification: _______________________________________

   5. Reason for disqualification: _______________________________________

The following space is provided for further explanations of the answers to any questions asked in this Prequalification Questionnaire.

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