HomeMy WebLinkAboutBiddersProofFormCITY OF OSHKOSH
BIDDER’S PROOF OF RESPONSIBILITY
FOR CONSTRUCTION YEAR 2026
ALL BIDDERS ON PUBLIC WORKS CONTRACTS
SHALL PROVIDE PROOF OF RESPONSIBILITY IN ACCORDANCE
WITH SECTION 66.0901(2), WISCONSIN STATE STATUTES.
RETURN QUESTIONNAIRE TO:
DIRECTOR OF PUBLIC WORKS
CITY HALL, ROOM 301
215 CHURCH AVENUE
PO BOX 1130
OSHKOSH, WI 54903-1130
E-MAIL: dpw@oshkoshwi.gov
NOTE:
THE CONTENTS OF THIS QUESTIONNAIRE SHALL BE CONFIDENTIAL
FOR THE EXCLUSIVE USE OF THE CONTRACTING AGENCY
AND SHALL NOT BE MADE PUBLIC EXCEPT
BY WRITTEN PERMISSION OF THE PROSPECTIVE BIDDER.
(REVISED OCTOBER 15, 2025)
DO NOT REMOVE THIS COVER SHEET FROM THIS DOCUMENT
ANSWERS MUST BE TYPEWRITTEN OR IN INK.
(Revised 10/15/25) Page 1 of 16
PREQUALIFICATION STATEMENT
There is submitted herewith for your consideration, pursuant to Section 66.0901(2), Wisconsin State Statutes, a
statement of qualifications of the undersigned to furnish the necessary labor, materials, and skills required to
enter upon and complete Public Works Contracts to be let by the City of Oshkosh.
I. IDENTIFICATION
A. Official Firm Name _____________________________________________________________
B. General Telephone _____________________ FAX __________________________________
C. Mailing Address _______________________________________________________________
(Street)
______________________________________________________________________________
(City) (State) (Zip Code)
D. General E-Mail Address ________________________________________________________
E. Number of years in business under present firm name ______________________________
F. Please check (1), (2) or (3):
(1) A Corporation or LLC (2) A Co-Partnership (3) An Individual
G. Principal Individuals:
(If a Corporation or LLC, answer below) (If a Co-Partnership, answer below)
President _____________________ Name of Partner ______________________
Vice Pres. ____________________ Name of Partner ______________________
Secretary _____________________ (If a Sole Trader, answer below)
Treasurer _____________________ Name of Sole Trader ___________________
H. If a Corporation or LLC, answer below:
(1) When incorporated ______________, (2) In what State ______________________
(Revised 10/15/25) Page 2 of 16
I. Contact information for questions regarding this form:
Person’s Name ________________________________________________________________
Telephone _________________________ FAX ___________________________________
E-Mail Address _________________________________________________________________
Total Contract Amount for which firm is seeking prequalification:
Firm must have been the Prime Contractor and have completed at least two (2) contracts/projects of similar
scope/type within the last three (3) years with a Total Contract Amount of at least the amount for which firm is
seeking prequalification. If approved, Contractor will be automatically approved for all lower amounts.
$500,000
$750,000
$1,500,000
$3,000,000
$5,000,000
In Excess of $7,000,000
(Revised 10/15/25) Page 3 of 16
Class of work in which firm is seeking prequalification (check below – may check multiple boxes):
STREET, UTILITY, & SITE CONSTRUCTION GENERAL BUILDING CONSTRUCTION
Roadway Grading Building Construction, Renovation, or Remodeling
Concrete Pavement Construction,
including Grading
SPECIFIC CATEGORIES OF
Bituminous Paving BUILDING CONSTRUCTION
Bituminous Street Construction, Building Demolition
including Concrete Curb and Gutter,
and Roadway Grading and Graveling Elevator
Mudjacking Electrical
Joint Sealing Heating, Ventilating, and Air Conditioning
Sidewalk Construction Painting
Sanitary and Storm Sewer Construction Plumbing
Site Grading Treatment Facilities, Pump Houses and Lift
Stations
Street Lighting Roofing
Reinforced Concrete Construction, Riverwalk Construction
i.e. Foundations, Storm Drainage
Structures, Retaining Walls
Landscaping OTHER MISCELLANEOUS CATEGORIES
Bridge Painting ______________________________________
Water Main Construction ______________________________________
Boring or Tunneling ______________________________________
Sanitary and Storm Sewer Trenchless ______________________________________
Rehabilitation
(Revised 10/15/25) Page 4 of 16
II. EXPERIENCE
A. What is the construction experience of the principal individuals, including superintendents and/or
foremen, of your present organization?
Individual’s
Name
Present
Position of
Individual
in your
Organization
Years of
Construction
Experience
Magnitude &
Type of Work,
In What Capacity
Names of
Previous
Employers for
Past 10 Years*
*If this is their current employer, so state.
Average number of employees during the last 12 months:
Office __________ Skilled __________ Unskilled __________
B. WORK ON HAND
List below the present contracts held by you (not as subcontractor). If none, please enter “NONE”.
Attach additional sheets, if necessary. Additional sheets must contain same information as listed on
this page.
Date
Awarded
Owner/
Location Type of Work Percent
Completed
Anticipated
Completion
Date
Cost of
Work
Prime or
Sub?
C. PREVIOUS CONTRACTS
List below construction contracts held by the company completed for the last three (3) years
(not as subcontractor). Attach additional sheets, if necessary. Additional sheets must contain same
information as listed on this page.
Date Awarded Owner/Location Type of Work Cost of Work Prime or Sub?
D. Are you currently prequalified by the WDOT? Yes No
If yes, please submit a copy of the WDOT Notice of Contractor’s Prequalification.
(Revised 10/15/25) Page 5 of 16
III. EQUIPMENT
A. List below major pieces of equipment currently owned and available when needed for proposed work,
or submit a current copy of your depreciation schedule. All columns must be completed. Attach
additional sheets, if necessary. Additional sheets must contain same information as listed on this
page.
NUMBERS
OF ITEM
DESCRIPTION,
SIZE,
CAPACITY,
ETC.
ORIGINAL
COST
ACCUMULATED
DEPRECIATION
PRESENT
BOOK
VALUE
YEARS OF
SERVICE
(Revised 10/15/25) Page 6 of 16
IV. CONTRACTUAL RESPONSIBILITY
Answering “yes” to any of the following questions will not disqualify a company from becoming approved
to bid by the City of Oshkosh. However, failure to answer truthfully may result in disqualification for the
entire year.
A. Has your firm or any officer or partner of your firm ever been debarred, suspended, or disapproved by
the State of Wisconsin or the Federal Highway Administration in the past ten (10) years? Yes No
If so, state:
Date: _________________ Project Owner: __________________________
Project Owner’s Mailing Address: ____________________________________
(At that time or preferably now, if there is a difference)
Full particulars in each instance: (including type of work, amount of contract, cause of violation,
and resolution):
________________________________________________________________
________________________________________________________________
B. Has your firm or any officer or partner of your firm ever been debarred, suspended, disapproved, or
not pre-qualified by any government entity in the past ten (10) years? Yes No
If so, state:
Date: _________________ Project Owner: __________________________
Project Owner’s Mailing Address: ____________________________________
(At that time or preferably now, if there is a difference)
Full particulars in each instance: (including type of work, amount of contract, cause of violation,
and resolution):
________________________________________________________________
________________________________________________________________
(Revised 10/15/25) Page 7 of 16
C. Has your firm or any officer or partner of your firm had any type of business, contracting, or trade
license, certification, or registration revoked or suspended in the past ten (10) years? Yes No
If so, state:
Date: _________________ Project Owner: __________________________
Project Owner’s Mailing Address: ____________________________________
(At that time or preferably now, if there is a difference)
Full particulars in each instance: (including type of work, amount of contract, cause of violation,
and resolution):
________________________________________________________________
________________________________________________________________
D. Has your firm or any officer or partner of your firm ever committed a violation of federal, state, or local
government safety or environmental laws as determined by a fine, settlement, administrative order, or
final decision of a court or government agency authority in the past ten (10) years? This includes, but
is not limited to, any OSHA or WDNR violations. Yes No
If so, state:
Date: _________________ Project Owner: __________________________
Project Owner’s Mailing Address: ____________________________________
(At that time or preferably now, if there is a difference)
Full particulars in each instance: (including type of work, amount of contract, cause of violation,
and resolution):
________________________________________________________________
________________________________________________________________
(Revised 10/15/25) Page 8 of 16
E. Does your firm or any officer or partner of your firm have an open or ongoing investigation of a
violation of federal, state, or local government safety or environmental laws? This includes, but is not
limited to, any OSHA or WDNR violations. Yes No
If so, state:
Date: _________________ Project Owner: __________________________
Project Owner’s Mailing Address: ____________________________________
(At that time or preferably now, if there is a difference)
Full particulars in each instance: (including type of work, amount of contract, cause of violation,
and resolution):
________________________________________________________________
________________________________________________________________
F. Has your firm ever worked on any contract or work awarded to it that resulted in a lawsuit in the past
ten (10) years? Yes No
If so, state:
Date: _________________ Project Owner: __________________________
Project Owner’s Mailing Address: ____________________________________
(At that time or preferably now, if there is a difference)
Full particulars in each instance: (including type of work, amount of contract, cause of violation,
and resolution):
________________________________________________________________
________________________________________________________________
(Revised 10/15/25) Page 9 of 16
G. Has your firm or any officer or partner of your firm ever declared bankruptcy while performing work
on a contract or work awarded to it, or while an officer or partner of another firm in the past ten (10)
years? Yes No
If so, state:
Date: _________________ Project Owner: __________________________
Project Owner’s Mailing Address: ____________________________________
(At that time or preferably now, if there is a difference)
Full particulars in each instance: (including type of work, amount of contract, and resolution):
________________________________________________________________
________________________________________________________________
H. Has your firm ever defaulted on or failed to complete any contract or work awarded to it in the past ten
(10) years? Yes No
If so, state:
Date: _________________ Project Owner: __________________________
Project Owner’s Mailing Address: ____________________________________
(At that time or preferably now, if there is a difference)
Full particulars in each instance: (including type of work, amount of contract, cause of violation,
and resolution):
________________________________________________________________
________________________________________________________________
(Revised 10/15/25) Page 10 of 16
I. Has your firm ever been assessed liquidated damages or other penalties for failure to meet the contract
requirements for work awarded to it in the past ten (10) years? Yes No
If so, state:
Date: _________________ Project Owner: __________________________
Project Owner’s Mailing Address: ____________________________________
(At that time or preferably now, if there is a difference)
Full particulars in each instance: (including type of work, amount of contract, cause of violation,
resolution, and amount of penalties assessed):
________________________________________________________________
________________________________________________________________
J. Has any officer or partner of your firm ever defaulted or failed to complete a construction contract
handled in their own name in the past ten (10) years? Yes No
If so, state:
Date: _________________ Name of Officer/Partner: __________________
Project Owner: _____________________________________________________
Project Owner’s Mailing Address: _____________________________________
(At that time or preferably now, if there is a difference)
Full particulars in each instance: (including type of work, amount of contract, cause of violation,
and resolution):
___________________________________________________________________
___________________________________________________________________
(Revised 10/15/25) Page 11 of 16
K. Has any officer or partner of your firm ever been an officer or partner of some other organization that
defaulted or failed to complete a construction contract in the last ten (10) years? Yes No
If so, state:
Date: _________________ Name of Officer/Partner: _______________________
Name and Mailing Address of Organization: ________________________________
________________________________________________________________________
Name and Mailing Address of Project Owner: _______________________________
________________________________________________________________________
(At that time or preferably now, if there is a difference)
Full particulars in each instance: (including type of work, amount of contract, cause of violation,
and resolution):
_________________________________________________________________________
_________________________________________________________________________
L. Has your firm or any officer or partner of your firm asked to be relieved from a bid submitted by it to a
public awarding authority in the past ten (10) years? Yes No
If so, state:
Date: _______________________ Project Owner: ____________________________
Project Owner’s Mailing Address: _________________________________________
(At that time or preferably now, if there is a difference)
Full particulars in each instance: (including type of work, amount of contract, cause of violation,
and resolution):
_________________________________________________________________________
_________________________________________________________________________
(Revised 10/15/25) Page 12 of 16
M. Has your firm or any officer or partner of your firm ever been charged with or convicted of a violation
of any wage schedule in the past ten (10) years? Yes No
If so, state:
Date: _______________________ Claimant: ________________________________
Claimant’s Mailing Address: _____________________________________________
(At that time or preferably now if there is a difference)
Full particulars in each instance: (including type of work, amount of contract, cause of violation,
and resolution):
__________________________________________________________________________
__________________________________________________________________________
N. Has your firm; any of its owners; a subsidiary or corporate parent; or any officer, director, or partner
thereof, been convicted of violating Section 133.03 Wisconsin Statutes (Unlawful Contracts:
Conspiracies) in the last ten (10) years? Yes No
If so, state:
Date: _______________________ Claimant: _______________________
Claimant’s Mailing Address: ____________________________________
(At that time or preferably now, if there is a difference)
Full particulars in each instance: (including type of work, amount of contract, cause of violation,
and resolution):
_______________________________________________________________
_______________________________________________________________
(Revised 10/15/25) Page 13 of 16
V. SAFETY
A. Does your firm require the following safety training programs:
1. Right to Know/Hazard Communication Yes No
2. Fire Prevention Yes No
3. Hot Work Permits Yes No
4. Environmental Compliance Yes No
5. Excavation/Trenching Yes No
6. Working at Elevation > four feet (4’) Yes No
7. Confined Space Entry Yes No
8. Control Hazardous Energy (Lockout) Yes No
9. Operation of Powered Equipment/Vehicles Yes No
10. Working with Hazardous Voltages Yes No
11. Personal Protective Equipment Yes No
12. Process Safety Yes No
If you answered NO to any of the above, please comment:
_____________________________________________________________________
_____________________________________________________________________
B. Are the training records available upon request? Yes No
C. Please provide your Total OSHA Incident Rate and Lost Workday Rate for each of the last three (3)
years by completing the table below:
1. Year ________ _________ ________
2. Number of Employee Hours Worked ________ _________ ________
3. Number of Lost Workday Cases ________ _________ ________
4. Number of Cases Due to Injury or
Illness Defined as Recordable ________ _________ ________
5. Total Number of Recordable Cases
(Add 3 and 4 Above) ________ _________ ________
(Revised 10/15/25) Page 14 of 16
6. Calculate Your Incident Rate by Using
the Following Formula:
Total Cases on Line 5 x 200,000 Hours
Employee Hours on Line 2 ________ _________ ________
D. Please provide Name and Telephone Number for Individual Responsible for:
1. Safety Coordination: ______________________ _______________________
Name Telephone
2. Environmental Issues: ______________________ _______________________
Name Telephone
VI. BONDING RESPONSIBILITY
A. Provide the name of your bonding company and your firm’s current limit of Payment and Performance
Bonds:
Name: ________________________________________________________________
Dollar Limit: ___________________________________________________________
Names and addresses of all bonding companies other than those listed in “A” above which have
written bid and security bonds during the last five (5) years:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
B. Attach a current letter of reference from your principal bank. Include your current banking
relationship with your principal bank and your current line of credit, if you have a line of credit. The
submission of only your line of credit documentation is not sufficient.
(Revised 10/15/25) Page 15 of 16
C. Has any bonding company ever taken over a contract or made payments because of your firm’s failure
to carry out a contract? Yes No
If so, state:
Date: ______________ Name of Bonding Company: ______________________
Bonding Company’s Mailing Address: _________________________________
____________________________________________________________________
Full particulars in each instance: (including type of work, amount of contract, cause of violation,
and resolution):
___________________________________________________________________________
___________________________________________________________________________
VII. CONTRACTOR’S FINANCIAL STATEMENT
A. Attach your firm’s latest complete financial report (including Balance Sheet, Income Statement, and
Statement of Cash Flows) with the name of the Accountant who prepared it.
B. Are any of your assets assigned? If so, which are assigned?
_______________________________________________________________________
C. For what purpose are they assigned?
_______________________________________________________________________
(Revised 10/15/25) Page 16 of 16
VIII. AFFIDAVIT
STATE OF ____________________)
COUNTY OF ____________________)
______________________________________ being duly sworn, deposes and says that he/she
(Name of Officer/Owner)
is the ___________________________ of ___________________________________________
(Title) (Name of Firm)
and that the answers to the foregoing questions and all statements therein contained are true and correct, and
that any owner, bonding company, or other agency herein named is hereby authorized to supply the
municipality, City of Oshkosh, with any information deemed necessary to verify this statement.
______________________________________
(Signature of Officer/Owner)
Subscribed and sworn before me this ________ day of _________________, 20____.
______________________________________
Notary Public
_________________, ____________________
County State
My Commission Expires ________________
for Contracts with Prequalification
APPROVED BY: Limits of Not More Than:
__________________________________ Date ___________ _____________________________
Director of Public Works
___________________________________ Date ___________
City Manager
I:\Engineering\Contractors Prequalified to Bid\Bidder's Proof Form_10-15-25.docx