Professional Services Qualifications Statement

Description

PROFESSIONAL SERVICES QUALIFICATION STATEMENT* *Professional Services Qualification Statements (PSQS) will be kept on file at the NJEDA for two years from the date of submittal of a complete PSQS. An incomplete PSQS will be returned. All items must be completed. Attach as many sheets as necessary to complete a section. Should additional sheets be attached, please specify which section numbers the attachments pertain to. If an item is not applicable, indicate so by inserting “N/A”. Rev. 3/2021 1. Firm Name/Business Headquarters Address: Telephone No.: Fax No.: E-Mail Address: 5. Type of Ownership: Total Number of Employees: New Jersey Economic Development Authority Real Estate Development Division 36 West State Street, P.O. Box 990 Trenton, NJ 08625-0990 2. Submittal Date: 3. Federal ID No.: 4. NIGP Commodity Code: 6. (a) Is the applicant firm certified or registered with the New Jersey Division of Revenue as an: SBE WBE MBE DVOB VOB Name of Parent Company, if any: Year Present Firm Established: Former Firm Name(s) and Year(s) Established: ______ Yes ______ No ______ Yes ______ No (Optional) ______ Yes ______ No (Optional) ______ Yes ______ No (Optional ) ______ Yes ______ No (Optional) Identification Number: Attach Certification/Registration form 6. (b) Is the applicant firm registered with the New Jersey Division of Revenue: ______ Yes ______ No Attach Business Registration form -1- 7. Principal Contact (include Name, Title and Telephone No.): 9. Check below the discipline for which the applicant firm is submitting its PSQS: (If submitting in more than one area, submit all appropriate documentation for each for each discipline.) CHECK IF APPLICABLE 8. DISCIPLINE Boundary/Topographic Survey Services Civil Engineering and Geotech Services Integrated Architectural/Engineering Services Architectural Design and Programming Services Planning Services Construction Inspection Services Environmental Engineering & Site Investigation Services Asbestos Inventory, Abatement/ASCM Services 10. LIST PRINCIPAL OWNERS: LIST KEY PERSONNEL: a. Name: a. Name: b. Home Address: b. Title: c. Percentage of Ownership: -2- List Branch Office locations other than Headquarters listed in Item 1: d. Officer/Title: a. Name: a. Name: b. Home Address: b. Title: c. Percentage of Ownership: d. Officer/Title: a. Name: a. Name: b. Home Address: b. Title: c. Percentage of Ownership: d. Officer/Title: -3- 11.