Company Name: Company Address: Company Phone: Fax: Owners Name: Contact Name: Type of License: Issuing Jurisdiction: Tax ID: DUNS #:

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1 REQUEST FOR QUALIFICATIONS-"Contractor Application" Company Name: Company Address: Company Phone: Fax: Owners Name: Contact Name: Type of License: Issuing Jurisdiction: Tax ID: DUNS #: Types of Work Your Company is Qualified to Preform: Lead Abatement Lead Safe Practices (must have passed HUD Training or be state-certified) Asbestos Removal and Abatement (must be state certified) Methamphetamine Testing and Abatement Mold Testing and Removal Furnace Repair/Replacement Window replacement Radon Testing and Mitigation Other general rehab Fill out the following table for your main employees or subcontractors: Name License Type Other Licenses (e.g. Mechanical, electrical, etc.) 4

2 How many employees? Has your company worked for other non-profit housing associations, DURA, or other Metro Denver low-income housing rehab programs in the last 12 months? Check those that apply. Northeast Denver Housing Center Del Norte NEWSED SWIC DURA Other (please list) Has your company ever filed for bankruptcy? If yes, please explain Insurance Information Describe the level and type of insurance you carry Type Company Amount General Liability: Worker Compensation: Other: Other: List for which workers compensation insurance is carried: What types and amounts of insurance do you require your subcontractors to carry? 5

3 Please provide the names and phone numbers for four references that we may call. Have you ever not completed a contract with a homeowner or agency? If yes, please describe. Additional information that you would like us to know about you (certificates, languages, etc.)? Thank you for completing this form. Please submit this form, along with the requested information outlined in the RFQ. Please see RFQ for details. 6

4 SMALL / MINORITY / WOMEN OWNED BUSINESS CONCERN CERTIFICATION The bidder/offerer represents and certifies that it: (a) is is not a small business concern. Small business concern, as used in this provision, means a concern, including its affiliates, that is independently owned and operated, not dominant in the field of operation in which it is bidding and qualified under the criteria and size standards in 12 CFR 121. (b) is is not a woman owned small business concern. Women-owned, as used in this provision, means a small business that is at least 51 percent owned by a woman or women who are also U.S. citizens and who also control and operate the business. (c) is is not a minority enterprise which, pursuant to Executive Order is defined as a business which is at least 51 percent owned by one or more minority group members or, in the case of a publicly owned business, at least 51 percent of its voting stock is owned by one or more minority group members, and whose management and daily operations are controlled by one or more such individuals. For the purposed of this definition, minority group members are: (Check the block applicable to you) Black Americans Hispanic Americans Native Americans Asian Pacific Americans Asian Indian Americans Hasidic Jewish Americans Signature & Date Typed or Printed Name Organization Title 7

5 Certification as a Section 3 Business Concern Name of Business: Address of Business: Contact Person: Title: I understand that my contract with BRI s program is subject to the requirements of Section 3 of the Housing and Urban Development Act of 1968, as amended AND to the Section 3 Plan for this Project. I certify that the firm of (company s name) is a bonafide Section 3 company, and that it meets the following definition of a Section 3 business (check one): 1. 51% or more of this company is owned by Section 3 residents, as defined by the developer of this project. (Individuals whose household incomes are NO GREATER THAN 80% of Area Median Income: Please reference the attached chart included to determine if employee is less than 80% of current area median income) 2. Currently at least 30% of the employees of the company are Section 3 residents, as defined by the developer of this project. (Full time, permanent employees who have or had household incomes that are NO GREATER THAN 80% of Area Median Income within the last 3 years: Please reference the attached chart included to determine if employee is less than 80% of current area median income) 3. At least 30% of the employees of the company were Section 3 residents, as defined by the developer of this project, within three years of the date of first employment with this company. (Individuals whose household incomes are NO GREATER THAN 80% of Area Median Income: Please reference the attached chart included to determine if employee is less than 80% of current area median income) 4. I commit to subcontract at least 25% of the total value of this contract to Section 3 subcontractors, and to provide the necessary evidence to substantiate this. (Businesses that are either 51% owned by Section 3 residents or 30% or more of its employees are Section 3 residents) Adams County MSA 2014 Income Limits Family Size Annual Household Income (Less Than) $42,950 $49,100 $55,250 $61,350 $66,300 $71,200 $76,100 $81,000 I hereby certify that the information provided by me to be true and correct, and understand any falsification of any of the information could subject me to disqualification from participation. Signature of Chief Executive Officer Date 8