Application: RFQ for Construction Services
Please review the Request for Qualifications (RFQ) before proceeding with the application. The RFQ includes contractor's acknowledgment form which must be signed and submitted with this application.
Company Name
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EIN
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Contact Person
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Has your firm provided housing rehabilitation construction services to Pike County in the past?
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Yes
No
Is the business a Section 3 business concern?
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Yes
No
Is the business minority-owned?
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Yes
No
Is the business woman-owned?
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Yes
No
Provide a brief history of your firm and describe your current structure.
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Describe your firm's experience with providing housing rehabilitation inspection services.
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Describe your firm's financial capacity to provide this service.
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Contractor's Acknowledgment (see RFQ above)
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Valid PA Contractor's License
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EPA Lead Safe Certification
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Evidence of Required Insurance
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LOBBYING CERTIFICATION: The undersigned certifies, to the best of his or her knowledge and belief, that:No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employe of any agency, a member of Congress, an officer or employe of Congress, or an employe of a member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement.If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employe of any agency, a member of Congress, an officer or employe of Congress, or an employe of a member of Congress in connection with this federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, “Disclosure of Lobbying Activities,” in accordance with its instructions.The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed under Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for such failure.
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By signing below, I hereby certify that all information contained in this application is true and accurate.
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Today's Date
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Month
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Day
Year
Date
Submit
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