Commonwealth of Pennsylvania s13

CS-4300 (06/2007) Part 1 PENNSYLVANIA DEPARTMENT OF TRANSPORTATION BUREAU OF CONTRUCTION & MATERIALS 400 NORTH STREET – 7th FLOOR WEST HARRISBURG, PENNSYLVANIA 17120-0094

CONFIDENTIAL PART 1

CONTRACTOR’S FINANCIAL STATEMENT

NOTE: All requested information must be submitted in the format displayed on this form. The Department will not accept any substitute submission of the requested information. This form must be completed in total.

Contractor  A Corporation

Business Address Street P.O. Box No. State of Incorporation

 A Co-Partnership City State Zip Code  An Individual Telephone Number ( ) ______Fax Number ( )______ Affiliate/Subsidiary/ Division

Business Partner Registration Number

Date Submitted

FOR DEPARTMENT USE ONLY:

Financial Statement

Part 1, Page 1 CS-4300 (06/2007) Part 1 Examined/Accepted By: Accountant Date CS-4300 (06/2007) Part 1

REVIEWED FINANCIAL STATEMENT

Section 457.4(b) of the Prequalification Regulations allows for the acceptance of a Reviewed Financial Statement under certain conditions. In order to provide clarification as to how the Department intends to implement this provision of the Prequalification Regulations, the following information is provided:

 A review statement will be accepted if the net working capital, as determined by the Comptroller’s Office,  is less than $50,000.

 A review statement will not be accepted if the net working capital, as determined by the Comptroller’s Office, is negative.

 A review statement will not be accepted if the Maximum Capacity Rating (Q) as calculated in Section 457.5(f) exceeds four million dollars ($4,000,000.00).

 If a Review Statement is not acceptable, you will be informed in writing by the Department that one of the following options is available for consideration:

(a) A current audited financial statement may be submitted for the Department’s evaluation.

(b) Prequalification as a subcontractor may be requested as noted in Section 457.4(a)(5). Submission of Part 1, Financial Statement, is not required for subcontractor approval.

 An Accountant’s Certificate to accommodate a Review Statement has been inserted for your use, if necessary, following this sheet.

Part 1, Page 2 CS-4300 (06/2007) Part 1

ACCOUNTANTS CERTIFICATE

I (We) have reviewed the accompany balance sheet and related financial statement of ______

______for the period ended ______, in accordance with standards

established by the American Institute of Certified Public Accountants. All information included in these financial

statements is the representation of the management of the company.

A review consists principally of inquiries of company personnel and analytical procedures applied to financial

data. It is substantially less in scope than an examination in accordance with generally accepted auditing standards, the

objective of which is the expression of an opinion regarding the financial statements taken as a whole. Accordingly,

we do not express such an opinion.

Based on our review, we are not aware of any material modifications that should be made to the accompanying

financial statements in order for them to be in conformity with generally accepted accounting principles.

Registration Number ______Signed ______Name of Certified Public Accountant/Public Accountant

______Accounting Firm Name

Authorized to do business in ______State

______Address

Part 1, Page 3 CS-4300 (06/2007) Part 1

ACCOUNTANTS CERTIFICATE

______Date I (We) have audited the balance sheet and related financial statements of ______for the period ended ______. These statements are the responsibility of the company’s management. Our responsibility is to express an opinion on these statements based on our audits. We conducted our audits in accordance with generally accepted auditing standards. Those standards require that we plan and perform the audit to obtain reasonable assurance whether the financial statements are free of material misstatement. Our audit included examining, on a test basis, evidence supporting the amounts and disclosures in the financial statements. Our audit also included assessing the accounting principles used and significant estimates made by management, as well as evaluating the overall financial statement presentation. Any lines of credit extended by banks were also verified. We believe that our audits provide a reasonable basis for our opinion. In our opinion, the financial statements referred to above present fairly, in all material respects, the financial position of______as of ______, in conformity with generally accepted accounting principles.

Registration Number ______Signed______Name of Certified Public Accountant/Public Accountant

______Accounting Firm Name

Authorized to do business in ______State

______Address

Part 1, Page 3 CS-4300 (06/2007) Part 1

BALANCE SHEET [see pg. 7] as of  A Corporation Submitted by ______ A Co-Partnership Date  An Individual ASSETS ADJUSTED WORKING CAPITAL [see pg.7-(b)] A. CASH ______$______1. On Hand ______$______$______2. In Banks (Unrestricted) ______3. Elsewhere (Unrestricted) ______4. Other ______B. BID DEPOSITS, GUARANTIES______$______C. ACCOUNTS RECEIVABLE (Less Related Reserves) ______$______1. Completed Contracts (Exclude Claims not yet Approved) ______$______2. Uncompleted Contracts (Monthly Estimates Exclusive of Retainage) ______3. Affiliated Companies (Due within one year) ______4. Other______D. NOTES AND ACCEPTANCES RECEIVABLE ______$______1. Trade (Portion due within one year) ______$______2. Affiliated Companies (Due within one year) ______3. Other ______E. INVESTMENTS ______$______1. Listed Stocks and Bonds [see pg.7-(c )] ______$______2. Unlisted Stocks and Bonds (Exclude stock in Affiliated Companies) [see pg.7-(d)] ______3. Joint Ventures [see pg.7-(e)] ______4. Other ______F. INVENTORIES ______$______1. Materials, Supplies, Stock Available for Contracts or Sale ______$______2. Other ______G. ACCRUED INCOME ______$______1. Work in Progress – Unbilled (Include Retainage) ______$______2. Other ______H. PREPAID EXPENSES ______$______I. PLANT PROPERTY (Less Reserve for Depreciation) ______$ ______1. Machinery and Equipment (Used in Operation of Business) ______$______2. Land and Buildings (Used in Operation of Business) ______3. Furniture and Fixtures ______J. OTHER ASSETS ______$ ______1. Land and Buildings – Not Used in Operation of Business ______2. Other ______TOTAL ASSETS ______$______$______

Part 1, Page 3 CS-4300 (06/2007) Part 1

BALANCE SHEET (continued)

LIABILITIES AND NET WORTH ADJUSTED WORKING LIABILITIES: CAPITAL K. NOTES PAYABLE ______$______1. Banks, Trade, Sundry (Due within one year) ______$______$______2. Affiliated Companies (Due within one year) ______3. Other ______L. ACCOUNTS PAYABLE ______$______1. Payable to Subcontractors ______$______$______2. Trade ______$______3. Affiliated Companies ______$______4. Other ______$______M. ACCRUED TAXES ______$______1. Income ______$______$______2. Other ______$______N. ACCRUED SALARIES, WAGES AND OTHER EXPENSES ______$______$______O. MORTGAGES AND BONDS PAYABLE ______$______1. Due within one year ______$______$______2. Other ______$______P. OTHER LIABILITIES ______$______

TOTAL LIABILITIES ______$______$______

NET WORTH: Q. INDIVIDUAL OR PARTNERSHIP CAPITAL ______$______R. CAPITAL STOCK: ______$______1. Common ______$______2. Preferred ______$______S. SURPLUS ______$______1. Appropriated ______$______2. Unappropriated ______$______3. Paid-In ______$______T. TOTAL CAPITAL AND SURPLUS ______$______1. Less: Treasury Stock ______$______

TOTAL NET WORTH ______$______

TOTAL LIABILITIES AND NET WORTH ______$______Part 1, Page 3 CS-4300 (06/2007) Part 1

BALANCE SHEET OF ______as of ______

CONTINGENT LIABILITIES:

Liability on notes receivable discounted or sold $______Liability on accounts receivable pledged, assigned or sold ______Liability as bondsman ______Liability as guarantor on contracts or on accounts of others ______Liability under any judgements, suits or claims pending against you or any member of your firm ______Other contingent liabilities (itemize) ______

Total $______

Instructions For Balance Sheet:

(a) The Balance Sheet shall reflect financial condition in accordance with generally accepted accounting principles.

(b) The contractor shall enter applicable amounts on all the lines provided. The Pennsylvania Department of Transportation shall review items excluded from the Adjusted Working Capital column and determine the propriety of any further inclusions. The Department reserves the right of final determination of all items and may make verification thereof to the extent deemed necessary.

(c) Use market value rather than cost for listed stocks and bonds.

(d) Use of the lower of cost or market for unlisted stocks and bonds.

(e) That share of Adjusted Working Capital of the joint venture, which is attributable to the contractor being evaluated. Furnish supporting data.

(f) If more space is required for data on supporting schedules, attach additional sheets.

Part 1, Page 3 CS-4300 (06/2007) Part 1

DETAILS RELATIVE TO ASSETS

SCHEDULE A – CASH

BALANCE SHEET ITEM NAME AND LOCATION OF BANK OR OTHER DEPOSITORY DEPOSITED IN NAME OF AMOUNT

TOTAL $ Indicate how much is restricted as to use for purposes other than current operations. Describe – $ SCHEDULE B – BID DEPOSITS, GUARANTIES

BALANCE DEPOSITED WITH: NAME AND ADDRESS PURPOSE OF DEPOSIT DATE DATE AMOUNT SHEET ITEM DEPOSITED RECOVERABLE $

TOTAL $

Part 1, Page 3 CS-4300 (06/2007) Part 1

SCHEDULE C – ACCOUNTS RECEIVABLE PART 1 Accounts Receivable from completed contracts exclusive of claims not yet approved for payments: BALANCE DESIGNATION OF CONTRACT NAME AND ADDRESS OF OWNER AMOUNT OF AMOUNT WHEN DUE SHEET ITEMS CONTRACT RECEIVABLE $ $

TOTAL $ Have any of the above been assigned, sold or pledged? ______If so, state amount , to whom, and reason ______

SCHEDULE C – ACCOUNTS RECEIVABLE Accounts Receivable from uncompleted contracts: Amount Due on monthly estimates exclusive of retainage (Col. 4) $ ______PART 2 Note: Transfer Total from Col. 5 to Schedule G – Accrued Income BALANCE DESIGNATION OF AMOUNT OF TOTAL AMOUNT CASH PREVIOUSLY Amounts Due on Unbilled Balance SHEET CONTRACT AND NAME AND CONTRACT EARNED AS OF RECEIVED Outstanding of Total Earned ITEM ADDRESS OF OWNER BALANCE SHEET Monthly Estimates Including DATE Exclusive of Retainage Due* Retainage (1) (2) (3) (4) (5) $ $ $ $ $

TOTAL $ $ $ $ Have any of the above been assigned, sold or pledged? ______If so, state amount, to whom, and reason ______*”Retainage Due” includes Securities held in lieu of retainage

Part 1, Page 3 CS-4300 (06/2007) Part 1

SCHEDULE C – ACCOUNTS RECEIVABLE (cont’d) PART 3 Accounts receivable from other than construction contracts: BALANCE RECEIVABLE FROM: NAME AND ADDRESS DESCRIPTION WHEN DUE AMOUNT SHEET ITEM $

TOTAL $ Have any of the above been assigned, sold or pledged? ______If so, state amount , to whom, and reason ______

SCHEDULE D – NOTES AND ACCEPTANCES RECEIVABLE BALANCE RECEIVABLE FROM: NAME AND ADDRESS DATE OF MATURITY HOW SECURED FACE VAULE SHEET ITEM $

TOTAL $

Indicate your contingent liability for discounted notes and acceptances receivable: WITH WHOM DISCOUNTED – ADDRESS MAKER OF NOTE DATE OF MATURITY FACE VALUE

TOTAL $

Part 1, Page 2 CS-4300 (06/2007) Part 1

SCHEDULE E – INVESTMENT PART 1 STOCKS AND BONDS (Do Not Include Securities Deposited With State Treasurer in Lieu of Retainage) *Indicate by asterisk stocks and bonds which are unlisted BALANCE DESCRIPTION NAME AND ADDRESS OF ISSUING QUANTITY PRESENT COST AMOUNT SHEET COMPANY MARKET (BOOK VALUE) PLEDGED OR IN ITEM VALUE ESCROW $ $ $

TOTAL $ $ $

If pledged or in Escrow, state for whom and reason:

SCHEDULE E – INVESTMENTS PART 2 – JOINT VENTURES FURNISH BALANCE SHEET OR STATEMENT OF WORKING CAPITAL FOR JOINT VENTURES BALANCE SHEET ITEM NAME AND DESCRIPTION OF ENTERPRISE CONTRACTORS NET AMOUNT OF CONTRACTOR’S RATIO OF INVESTMENT JOINT VENTURE WORKING CAPITAL

TOTAL $

Part 1, Page 10 CS-4300 (06/2007) Part 1

SCHEDULE F - *INVENTORIES: -MATERIALS, OPERATING-MAINTENANCE SUPPLIES AND PARTS TO BE CONSUMED BALANCE SHEET DESCRIPTION OF MATERIAL QUANTITY BOOK VAULE ITEM

TOTAL $

SCHEDULE G – ACCRUED INCOME Part 1, Page 10 CS-4300 (06/2007) Part 1

BALANCE DESCRIPTION DATE OF EXPECTED AMOUNT SHEET ITEM RECEIPT OR CREDIT $

TOTAL $

SCHEDULE H – PREPAID EXPENSES BALANCE DESCRIPTION WHEN DUE AMOUNT SHEET ITEM $

TOTAL $

Part 1, Page 10 CS-4300 (06/2007) Part 1

SCHEDULE I- PLANT PROPERTY PART 1 – MACHINERY AND EQUIPMENT (BOOK VALUE) USED IN OPERATION OF BUSINESS BALANCE QUANTITY DESCRIPTION AND CAPACITY OF ITEMS AGE OF PURCHASE DEPRECIATION BOOK SHEET ITEMS PRICE CHARGED OFF VAULE ITEM $ $

TOTAL $ Total amount of equipment pledged as security for loans $______

Part 1, Page 10 CS-4300 (06/2007) Part 1

SCHEDULE I – PLANT PROPERTY PART 2 – LAND AND BUILDINGS (BOOK VALUE) USED IN OPERATION OF BUSINESS

BALANCE SHEET DESCRIPTION AND TITLE HELD IN TOTAL COST ASSESSED VALUE BOOK VALUE AFTER ITEM LOCATION OF WHOSE NAME INCLUDING DEPRECIATION PROPERTY IMPROVEMENTS CHARGED OFF $ $ $

TOTAL $

SCHEDULE I – PLANT PROPERTY PART 3 – FURNITURE AND FIXTURES (BOOK VALUE)

BALANCE DESCRIPTION AMOUNT SHEET ITEM (BOOK VALUE) $

TOTAL $

Part 1, Page 10 CS-4300 (06/2007) Part 1

SCHEDULE J – OTHER ASSETS PART 1 – LAND AND BUILDINGS OWNED BUT NOT USED IN OPERATION OF BUSINESS (BOOK VALUE)

BALANCE DESCRIPTION AND LOCATION OF PROPERTY TITLE HELD IN COST DEPRECIATION BOOK SHEET ITEM WHOSE NAME RESERVE VALUE $ $ $

TOTAL $

SUPPLEMENTARY DATA:

For Individual or Co-Partnership Personally Owned Real Estate Not Connected with the Business

DESCRIPTION OF LOCATION OF PROPERTY TITLE HELD IN WHOSE NAME ENCUMBRANCE ASSESSED PROPERTY AGAINST VALUE PROPERTY $ $

SCHEDULE J – OTHER ASSETS PART 2 – OTHER

BALANCE DESCRIPTION: (Describe Fully) AMOUNT SHEET ITEM $

TOTAL $

Part 1, Page 10 CS-4300 (06/2007) Part 1

DETAILS RELATIVE TO LIABILITIES AND NET WORTH SCHEDULE K – NOTES PAYABLE BALANCE PAYEE: NAME AND ADDRESS MATURITY HOW CURRENT LONG SHEET DATE SECURED PORTION TERM ITEM (K-1) (K-2) PORTION (K-3) $ $

TOTAL $ $

SCHEDULE L – ACCOUNTS PAYABLE PART 1 – PAYABLE TO SUBCONTRACTORS BALANCE DESIGNATION OF CONTRACT TOTAL AMOUNT OF WORK VALUE OF WORK DONE AMOUNT AMOUNT DUE SHEET AND NAME OF LET TO SUBCONTRACTOR BASED ON LAST ESTIMATE PAID TO SUBCONTRACTOR ITEM SUBCONTRACTOR APPROVED DATE INCLUDING RETAINAGE $ $ $ $

TOTAL $

Part 1, Page 10 CS-4300 (06/2007) Part 1

SCHEDULE L – ACCOUNTS PAYABLE

PART 2 – TRADE – AFFILIATED COMPANIES – OTHER

BALANCE CREDITOR: NAME AND ADDRESS DESCRIPTION DATE PAYABLE AMOUNT SHEET ITEM $

TOTAL $

SCHEDULE M – ACCRUED TAXES

BALANCE NATURE OF TAX FOR WHAT PERIOD PAYABLE TO DATE AMOUNT SHEET ITEM PAYABLE $

Part 1, Page 10 CS-4300 (06/2007) Part 1

TOTAL $

SCHEDULE N – ACCRUED SALARIES, WAGES, INTEREST AND OTHER EXPENSES

BALANCE DESCRIPTION PERIOD COVERED DATE AMOUNT SHEET ITEM PAYABLE $

TOTAL $

SCHEDULE O– MORTGAGES AND BONDS PAYABLE PART 1 -MORTGAGES PAYABLE

BALANCE DESCRIPTION HOLDER OF LIEN MATURITY DATE HOW AMOUNT SHEET ITEM (Term – Interest Rate) NAME – ADDRESS SECURED $

Part 1, Page 10 CS-4300 (06/2007) Part 1

TOTAL $

SCHEDULE O– MORTGAGES AND BONDS PAYABLE PART 2 BONDS PAYABLE BALANCE DESCRIPTION (Bondholder – Interest Rate) HOW SECURED DATE DUE FACE SHEET ITEM VALUE $

TOTAL $

SCHEDULE P – OTHER LIABILITIES BALANCE DESCRIPTION AMOUNT SHEET ITEM $

TOTAL $

SCHEDULE Q – INDIVIDUAL OR PARTNERSHIP CAPITAL BALANCE NAME AND ADDRESS CAPITAL NET INCREASE CAPITAL SHEET ITEM BEGINNING OF (DECREASE) BALANCE PERIOD SHEET DATE $ $ $

Part 1, Page 10 CS-4300 (06/2007) Part 1

TOTAL $ $ $

SCHEDULE R – CAPITAL STOCK BALANCE KIND OF PAR VALUE AUTHORIZED OUTSTANDING TREASURY STOCK SHEET STOCK OR (NO. SHARES) ISSUED AMOUNT NO. SHARES COST PER AMOUNT ITEM *STATED VALUE (NO. SHARES) SHARE COMMON:

TOTALS $ $

PREFERRED: $

TOTALS $ $ *Show Amount per share if issued at premium or discount

SCHEDULE S – SURPLUS BALANCE SHEET APPROPRIATED SURPLUS: AMOUNT ITEM $

TOTAL APPROPRIATED SURPLUS $

TOTAL UNAPPROPRIATED SURPLUS $ PAID-IN SURPLUS: $

Part 1, Page 10 CS-4300 (06/2007) Part 1

TOTAL PAID-IN SURPLUS $

LINE-OF-CREDIT STATEMENTS

Line-of-Credit Statements may be submitted from your banks for the purpose of establishing your financial qualifications in determining your classification and rating. Such statements must, however, be specific as to amount.

The next page, properly executed, is the official form, which must be used for a bank line-of-credit statement. Any alterations will make the form null and void.

If more than one bank line-of-credit statement is being submitted the second or subsequent statements must be on the Pennsylvania Department of Transportation official form.

The name of the contractor being pre-qualified is the only name that is to be shown on the form.

Part 1, Page 10 CS-4300 (06/2007) Part 1

Name of Bank______Address______Date______Department of Transportation Prequalification Office 400 North Street – 7th Floor West Harrisburg, Pennsylvania 17120-0094

A line of credit in the maximum amount of $______has been placed at the disposal of ______

______for use when, as, and if needed throughout the one-year period beginning ______, subject to the usual conditions, including the requirement that the borrower’s financial condition and other circumstances remain satisfactory to the bank at the time of any proposed borrowing. Should there be any reduction, termination, or increase in this line of credit, the Department of Transportation would appreciate being notified of these changes as soon as possible. The banking facility will not be held accountable in any fashion by the Department.

The following items, listed as liquid assets in Part 1 of the questionnaire being submitted by ______have been pledged to secure the line of credit mentioned above:

*The line of credit mentioned has been given with full knowledge of accommodations extended by other banks in amounts as follows:

**It is not intended that this statement confer to the Department of Transportation or the Commonwealth of Pennsylvania any rights in and to

said line of credit nor shall this statement create any obligation of ______except as expressly set forth herein (Name of Bank)

AFFIDAVIT State of ______County of ______SS: ______being duly sworn, deposes and says that he is ______of the ______, the bank named in and which executed the foregoing statement. Sworn to before me this ______day of ______, (Year)

______(Notary Public) (Bank Officer Sign Here) Part 1, Page 10 CS-4300 (06/2007) Part 1

(NOTARIAL SEAL)

Part 1, Page 10 CS-4300 (06/2007) Part 1

FOR A CORPORATION COMPLETE THE FOLLOWING:

Corporate Name______Authorized Capital ______Paid-in Capital ______When Incorporated ______In What State ______

Name and Address of Officers:

President ______Vice-President ______Secretary ______Treasurer ______AFFIDAVIT FOR CORPORATION

STATE OF ______COUNTY OF ______SS:

The undersigned hereby declares: that the foregoing is a true statement of the financial condition of the corporation herein first named, as of the date herein first given; that this statement is in response to a questionnaire and that any depository, vendor or other agency herein named is hereby authorized to supply such party with any information necessary to verify this statement.

______being duly sworn, deposes and says that he is ______of the ______the (Title) corporation described in and which executed the foregoing statement; that he is familiar with the books of the said corporation showing its financial condition; that the foregoing financial statement, taken from the books of the said corporation, is a true and accurate statement of the financial condition as of the date thereof and that the answers to the foregoing interrogatories are true.

Sworn to before me this ______day of ______, (Year) ______(Signature of Officer) ______Notary Public (NOTARIAL SEAL) Corporate Seal Part 1, Page 2 CS-4300 (06/2007) Part 1

FOR A CO-PARTNERSHIP COMPLETE THE FOLLOWING:

Firm Name ______Date of Organization ______State whether Co-partnership is general or limited ______If limited, explain fully ______

Name and Address of Partners:

______

AFFIDAVIT FOR CO-PARTNERSHIP

STATE OF ______COUNTY OF ______SS: The undersigned hereby declares: that the foregoing is a true statement of the financial condition of the co-partnership herein first named, as of the date herein first given; that this statement is in response to a questionnaire and that any depository, vendor or other agency herein named is hereby authorized to supply such party with any information necessary to verify this statement.

______being duly sworn, deposes and says that he is a member of the firm of ______; that he is familiar with the books of the said firm showing its financial condition; that the foregoing financial statement, taken from the books of the said firm, is a true and accurate statement of the financial condition of the said firm as of the date thereof and that the answers to the foregoing interrogatories are true. Sworn to before me this ______day of ______, (Year) Signatures ______(ALL PARTNERS OF FIRM MUST SIGN) ______(NOTARY PUBLIC) ______Part 1, Page 2 CS-4300 (06/2007) Part 1

(NOTARIAL SEAL) ______

FOR AN INDIVIDUAL COMPLETE THE FOLLOWING:

Firm Name ______

AFFIDAVIT FOR INDIVIDUAL

STATE OF ______COUNTY OF ______SS:

The undersigned hereby declares: that the foregoing is a true statement of the financial condition of the individual herein first named, as of the date herein first given; that this statement is in response to a questionnaire and that any depository, vendor or other agency herein named is hereby authorized to supply such party with any information necessary to verify this statement.

______being duly sworn, deposes and says that the foregoing financial statement, taken from his books, is a true and accurate statement of his financial condition as of the date thereof and that the answers to the foregoing interrogatories are true.

Sworn to before me this

______day of ______, (Year) ______(SIGNATURE OF INDIVIDUAL)

______(NOTARY PUBLIC)

(NOTARIAL SEAL)

Part 1, Page 25 CS-4300 (06/2007) Part 2

PENNSYLVANIA DEPARTMENT OF TRANSPORTATION BUREAU OF CONSTRUCTION & MATERIALS 400 NORTH STREET – 7TH FLOOR WEST HARRISBURG, PENNSYLVANIA 17120

CONFIDENTIAL – PART 2 ORGANIZATION AND EXPERIENCE STATEMENT

Name of Company ______

Address ______

______

Telephone & Fax Numbers ______

Federal Identification No. ______

Business Partner Registration No. ______(REQUIRED)

OUT-OF-STATE CONTRACTOR - Pennsylvania Resident Agent

Name ______

Address ______

______

NOTE: The Department reserves the right to request additional information for prequalification at any time as per the requirements of Title 67 Transportation, Section 457.17, Notification.

Form completed by (print): ______

Title: ______

Part 2, Page 1 CS-4300 (06/2007) Part 2

APPLICATION

The undersigned hereby applies for qualification to perform the following types of work, as described in the Pennsylvania Department of Transportation Specifications, Publication 408M (408).

WORK CLASSIFICATION (CHECK THOSE DESIRED) WORK CODE CLASSIFICATION X EARTHWORK A Clearing & Grubbing B Building Demolition C Roadway Excavating & Grading C1 Non-Roadway, Drainage, Structure Related Excavation & Grading C2 Drilling & Blasting C5 Anchors C6 Drilling BASE COURSE C4 Rubblizing D Rigid Base Course E Flexible Base Course PAVEMENT F Bituminous Pavement F1 Bituminous Pavement Patching & Repair F2 Bituminous Joint &Crack Sealing F3 Milling, Rumble Strips, Scarification (Bituminous or Concrete) F4 Bituminous SurfaceTreatments, Seal Coats G Rigid Pavement G1 Rigid Pavement Patching & Repair G2 Diamond, Carbide Grinding (Concrete or Bituminous) G3 Spall Repair G4 Joint Rehabilitation, Sawing & Sealing (Concrete or Bituminous) W Railroad Construction INCIDENTAL B1 Asbestos Removal CONSTRUCTION C3 Geotextiles H Drainage, Water Main, Storm Sewer H1 Pipe & Culvert Cleaning H2 Pavement Base Drains J Guide Rail, Steel Median Barrier, Fences J1 Concrete Median Barrier J2 Fencing, Railings K Curbs, Sidewalks, Inlets, Manholes, Etc. K1 Masonry Work K2 Concrete & Masonry Coatings L Slabjacking-Subsealing ROADSIDE M Landscaping M1 Selective Tree Removal, Trimming M2 Silt Barrier Fence, Gabions, Erosion Control M3 Seeding & Soil Supplements N Building Construction & Related Trades N1 Related Building Trades

Part 2, Page 2 CS-4300 (06/2007) Part 2

TRAFFIC O Pavement Markings ACCOMMODATIONS O1 Raised, Recessed Pavement Markers & CONTROL O2 Plastic Applications List O3 Paint Applications the P Highway/Sign Lighting, Traffic Signal Control P1 Camera Monitoring Systems(CCTV) P2 Highway Advisory Radio System (HAR) P3 Dynamic Message Signs (DMS) P4 Integrated Communications Systems P5 Level 1 (Hardware) System Integrator P6 Level 2 (Software) System Integrator P7 Level 3 (Hardware & Software) Integrator P8 Highway/Sign Lighting, Electrical Q Maintenance & Protection of Traffic R Sign Placement (Post/Structure Mounted) R1 Sign Structures S Cement Concrete Bridges Over 120’ (37M) STRUCTURES S1 Single Span Bridges to 120’ (37M) (Bridges) S2 Repair & Rehabilitation of Damaged Structures S3 Modified Concrete Deck Overlays S4 Bridge Culverts, Pedestrian Bridges, Timber Bridges S5 Structural Walls S6 Prestressed Beam Installation S7 Rebar Installation S8 Transportation Tunnels S9 Bridge Deck Placement or Repairs S0 Marine Work T Steel Bridges T1 Bridge Removal T3 Steel Bridges Over 120’ (37M) T4 Welding T5 Bearing Pads & Seals T6 Expansion Dams T7 Bridge Drainage T8 Shear Studs, Metal Bridge Deck Forms T9 Parapets U Pile Driving U1 Caissons V Steel Painting (High Performance) V1 Steel Painting (Conventional) V2 Steel Surface Preparation states in which you are prequalified for highway construction work and applicable maximum capacity rating:

STATE AMOUNT OF MAXIMUM CAPACITY RATING

______

Part 2, Page 3 CS-4300 (06/2007) Part 2

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

______

2. How many years experience in highway construction work has your organization had? ______

3. List the construction experience of the officers and management personnel including superintendents of your organization.

INDIVIDUAL’S PRESENT POSITION YEARS OF TYPE OF IN WHAT NAME OR TITLE CONSTRUCTION CONSTRUCTION POSITION EXPERIENCE WORK

4. Has your company ever failed to complete any work awarded to you? ______

If so, give dates, projects and reasons therefore______

______

5. Has any officer or partner of your organization ever been an officer or partner of some other organization that failed to complete a construction contract?

______

If so, state name of individual, other organization, dates, project, and reason therefore ______

______

6. Has any officer or partner of your organization ever failed to complete a construction contract handled in his own name?

______

If so, state name of individual, name of owner and reason therefore ______

______

7. Has your organization or an officer of your organization ever been denied prequalification in this state or any other state under this name or any other name? ______

If so, please indicate state(s), and explain reasons for denial______

______

Part 2, Page 4 CS-4300 (06/2007) Part 2

8. Has your organization or an officer of your organization ever been disqualified or removed from a bidding list in this State or any other state, or from a Federal Government bidding list under this name or any other name? ______

______

If so, please indicate state(s) and/or Federal agency and explain reasons for denial. ______

______

9. List all affiliated or subsidiary organizations and companies. ______

______

Please complete information on Part 2, Page 5 if you are requesting prequalification approval for subsidiary organizations and/or companies.

10. List all organizations and individuals that have a financial interest of ten percent (10%) or more in your company.

______

11. List all persons having a financial interest in this organization and who also have a financial interest in another organization prequalified or eligible to bid in this state or any other state. ______

______

12. List any other organization or individual who controls or influences the bidding of this organization. ______

______

Part 2, Page 5 CS-4300 (06/2007) Part 2

REQUEST FOR SUBSIDIARY PREQUALIFICATION

1) Name

Address

Telephone Number ( )

Fax Number ( )

Federal Identification No. ______

List of Officers, Management Personnel, and Superintendents:

Individual Name Position or Title

(Make additional copies if needed)

Part 2, Page 6 CS-4300 (06/2007) Part 2 13. List contracts which will show the various types of work completed by your organization in the past 5 years and/or presently under construction.

NAME AND ADDRESS NAME AND LOCATION NAME AND CONTRACT Was contract Were there any Were there any liens, OF OWNER* OF PROJECT – DETAIL ADDRESS OF AMOUNT completed on penalties claims, or stop DESCRIPTION OF PRIME time? imposed? notices filed against *Address must be adequate WORK PERFORMED CONTRACTOR job? to assure reply to inquiry (Include e.g. quantities, If “YES” give and verification. Failure to lengths, miles, sizes, types, If you were a (If subcontractor, indicate If “NO” explain amount and If “YES” explain receive reply will delay etc.) subcontractor subcontracted amount) why under explain under under Number 15. processing of application. Number 15. Number 15.

(Make additional copies if needed)

Part 2, Page 7 CS-4300 (06/2007) Part 2

14. PLANT AND EQUIPMENT

List equipment owned. Also list and indicate separately, equipment under lease or otherwise available to you, with attached explanation of the arrangements.

The list of equipment should be identical with those shown in your Financial Statement, and must be shown below to be credited with the technical evaluation of your application.

QUANTITY ITEM SIZE OR CONDITION YEARS OF CAPACITY SERVICE

Part 2, Page 8 CS-4300 (06/2007) Part 2

15. Explanation of details in connection with non-completion of contracts; penalties imposed; liens, claims and stop notices filed against contracts listed under No. 13. ______

______

16. Complete statement of misdemeanor convictions involving moral turpitude, convictions of bidding related crimes, and all felony convictions of the contractor, as well as the contractor’s directors, principal officers and key employees.______

______

17. Give any further or relevant, pertinent and material facts that will justify approval of the requested work classifications.______

______

18. If you are a parent organization and desire to do business in Pennsylvania through branch offices, indicate below the official name and address of each branch. Also indicate a mailing address if different than the address listed on the Cover Sheet, Page 1.

NAME ADDRESS

______

Part 2, Page 9 CS-4300 (06/2007) Part 2

NOTARY PAGE

Date at ______this ______day of ______, ______(year)

______NAME OF ORGANIZATION

______SIGNATURE AND TITLE OF PERSON SIGNING

COUNTY OF ______

COMMONWEALTH / STATE OF ______

______being duly sworn, deposes and says that he/she (PRINT NAME) is ______of ______(TITLE) (NAME OF ORGANIZATION) and that the answers to the foregoing questions and all statements therein contained are true and correct.

______day of ______, ______(year)

Notary Public

My commission Expires

(NOTARIAL SEAL)

Part 2, Page 10 CS-4300 (06/2007) Part 3

PENNSYLVANIA DEPARTMENT OF TRANSPORTATION BUREAU OF CONSTRUCTION & MATERIALS 400 NORTH STREET – 7TH FLOOR WEST HARRISBURG, PENNSYLVANIA 17120

CONFIDENTAL

PART 3

CONTRACTOR’S AFFIRMATIVE ACTION STATEMENT

Contractor ______

Equal Employment Policy Officer ______

Date Submitted ______

Business Partner Registration No. ______

For Department use only:

Accepted by: ______Signature/Title Date

Part 3, Page 1 CS-4300 (06/2007) Part 3

Pursuant to the provisions of Executive Order 1996-8; Nondiscrimination Clauses; Pennsylvania Human Relations Act; Pennsylvania Department of Transportation, Chapter 457 Regulations (Prequalification); Civil Rights Act of 1964, as amended; Executive Order 11246, as amended; 23, USC, Sec 22 of Federal-aid Highway Act of 1968; and other related laws:

1. It is the policy of the ______Co. to ensure that applicants are employed and that employees are treated, during employment, without regard to their race, religion, sex, age, color, national origin and/or disability. Such action shall include: employment upgrading, demotion, or transfer, recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship, pre-apprenticeship; and/or on-the-job training.

2. ______is the name of Contractor’s Equal Employment Policy Officer.

3. It is hereby agreed, as part of this prequalification, that the following steps be taken to ensure equal opportunity in employment:

a. Require that all advertisements for personnel contain the notation “An Equal Opportunity Employer M/F”* and that all advertisements be inserted in newspapers having a large general circulation in the area and among minority groups.

b. Utilize, direct and systematically recruit personnel through all public and private employee referral sources likely to yield qualified minority groups and female applicants, including but not limited to schools, colleges, minority groups, and female organizations. Establish and maintain a current list of minority and female recruitment sources, provide written notification to these recruitment sources and community organizations when the contractor or its unions have employment opportunities available; follow-up and maintain documentation of the organizations’ responses.

c. Encourage minority and female applicants through referral by current employees.

4. It is further hereby agreed, as part of this prequalification, that in order to ensure nondiscriminatory hiring, the following steps have been taken:

a. All members of company staff authorized to hire and discharge or to recommend such action are fully cognizant of the company’s Equal Employment Opportunity Policy and the Policy of the Department.

b. All work supervisors, personnel officers, company officers and other employees have been advised of our above-stated Equal Employment Opportunity Policy.

c. All labor unions and other recruitment sources will post in conspicuous places, available to employees, agents, applicants for employment, and other persons, a notice to be provided by the contracting agency setting forth the provisions of the Nondiscrimination Clause.

*M/F means Minority/Female Part 3, Page 3 CS-4300 (06/2007) Part 3

d. Cooperation will be aggressively sought with unions, where applicable, to develop programs to ensure qualified minorities and females equal opportunity for employment and training.

e. It is further agreed to diligently attempt in conjunction with the labor unions, where applicable, to obtain qualified minority and female representation in all classifications on the job and in all phases of the work.

f. The unions which represent our work force are: (If you are non-union, please indicate)

______

______and it has been their policy to accept for membership, qualified personnel without regard to race, religion, color, sex, age or ethnic origin.

5. As part of this prequalification, we will make use of apprenticeship and/or other training programs in one or more of the following ways:

a. Continually assisting minorities and females to enter pre-apprenticeship and apprenticeship training programs,

b. Actively aiding minority and female employees to increase skills to be eligible for upgrading,

c. Regularly participating in programs for equitable consideration of all applicants, for union apprenticeship, such programs having been approved by the Bureau of Apprenticeship and Training of the United States Department of Labor, and/or the Pennsylvania Apprenticeship and Training Council, where applicable.

d. We presently have apprenticeship or on-the-job training programs for the following skills and/or crafts: (If none, please state.)

______

6. Where the practices of a union, any training program or other source of recruitment will result in the exclusion of minorities and females, so that the contractor will be unable to meet its obligation under the Contract Compliance Regulations issued by the Governor’s Office of Administration, the United States Department of Labor, or this nondiscrimination clause, the contractor shall then employ and fill vacancies through other nondiscriminatory employment

Part 3, Page 2 CS-4300 (06/2007) Part 3 procedures.

7. Are you currently a recipient of contracts with the Commonwealth of PA in addition to PennDOT? If yes, please indicate agency(ies).

______YES ______NO ______

______

8. Has any federal or state agency conducted an EEO compliance review of your firm within the past two years? If yes, please indicate agency(ies) and date(s).

______YES ______NO

______

9 9. Does the contractor have a written Affirmative Action Plan? 10 ______YES ______NO

10. It is also agreed that:

a. When bids are being solicited, the contractor shall actively solicit bids from minority- disadvantaged and/or female subcontractors.

b. Officials will conduct systematic reviews in order to ensure that the company’s EEO program is implemented.

c. We shall physically include the provisions of this nondiscrimination clause and all other applicable EEO Clauses in every subcontract, [i.e., Commonwealth Nondiscrimination Clause, Management Directive 215.16 (6-99), Specific Equal Employment Opportunity Responsibilities, (23 USC); Notice of Requirement For Affirmative Action To Ensure Equal Employment Opportunity, (Executive Order 11246, as Amended); Required Contract Provisions Federal-Aid Construction Contracts, (FAR-CA, Sept. 1975); Item 1999-9999, Trainees and/or Equal Employment Opportunity (100% State)], so that such provisions will be binding upon each subcontractor.

d. We will submit any required training program (if applicable), in accordance with established Department procedures and Items 1999-9999 or 1999-0000 Trainees/Special Training Provisions. Required training program will be submitted 10 days following the Notice to Proceed.

1) Submit an Initial Report (EO-364) for each trainee prior to filling any training position(s).

Part 3, Page 2 CS-4300 (06/2007) Part 3

2) Submit monthly Training Reports (EO-365) in a timely manner.

11. We will furnish all information and reports required by Federal and State Rules and Regulations, as well as permit access to contractor’s employees, books, records and accounts by the Pennsylvania Department of Transportation and the Governor’s Office of Administration, for purposes of investigation to ascertain compliance.

12. We agree to notify all subcontractors, unions, vendors or suppliers of their responsibilities to comply with state and/or federal regulations.

13. We agree to send to each subcontractor, union, supplier of employees or materials the nondiscrimination clause.

14. We agree not to use subcontractors, vendors or suppliers on State contracts who are reported to be in noncompliance or unawardable by a State agency Contract Compliance Officer.

Part 3, Page 2 CS-4300 (06/2007) Part 3

NOTARY PAGE

Dated at ______this______day of ______, ______(year)

______NAME OF ORGANIZATION

______SIGNATURE AND TITLE OF PERSON SIGNING

COUNTY OF ______

COMMONWEALTH / STATE OF ______

______being duly sworn, deposes and says that he/she (PRINT NAME) is ______of ______(TITLE) (NAME OF ORGANIZATION) and that the answers to the foregoing questions and all statements therein contained are true and correct.

______day of ______, ______(year)

______Notary Public

My commission Expires

(NOTARIAL SEAL)

Part 3, Page 1