PRINCIPAL QUESTIONNAIRE

Transcription

1 PRINCIPAL QUESTIONNAIRE The Vendor Information Exchange System (VENDEX) questionnaires have been developed to collect information from vendors who wish to do business with the City. This information is collected to ensure that the City obeys the mandate of the New York City Charter to do business only with responsible vendors. All questions on these questionnaires must be answered and the answers typewritten or printed in ink. If you need more space to answer any question, make as many photocopies of the appropriate page(s) as necessary and attach them to the questionnaire. Refer to the booklet A Vendor s Guide To VENDEX for specific instructions for completing this questionnaire and for a definition of terms. Terms or phrases which are defined are written in bold face throughout the questionnaire. If you have not received a copy of this booklet or if you have additional questions that the booklet does not answer, contact the VENDEX Unit at COMPLETE THIS QUESTIONNAIRE CAREFULLY AND COMPLETELY. FAILURE TO SUBMIT A COMPLETE QUESTIONNAIRE MAY MEAN THAT YOUR BID OR PROPOSAL WILL BE REJECTED AS NON-RESPONSIVE AND IT WILL NOT BE CONSIDERED FOR AWARD. New York City Agency Bureau/Division Business Submitting EIN/SSN the Business Entity Questionnaire Type of Submission: (Check one) 1. Fully Completed Questionnaire 2. Changed Questionnaire If 2. checked, provide submission date of fully completed questionnaire / / Name (Principal Questionnaire completed by) Title Date 1. Principal name SSN Date of birth / / Home address Business address Telephone Other present address(es) Telephone List of other addresses and telephone numbers attached Principal Questionnaire - Page 1 of 13 Revised 1/92

2 2. Positions held in submitting business and starting date of each (check all applicable) President / / Treasurer / / Chairman of Board / / Shareholder / / Chief Exec. Officer / / Secretary / / Chief Financial Officer / / Partner / / Vice President / / / / (Other) 3. No Yes Do you have an equity interest in the business submitting the questionnaire? If yes, provide details on Page 6, Section No Yes Are there any outstanding loans, guarantees or any other form of security or lease or any other type of contribution made in whole or in part between you and the business submitting the questionnaire? If yes, provide details on Page 6, Section No Yes Within the past 3 years, have you been a principal owner or officer of any business or not-for-profit organization other than the one submitting the questionnaire? If yes, provide details on Page 6, Section No Yes Has New York City awarded any contracts to a business or organization listed in Section 5 in the past 3 years while you were a principal owner or officer? If yes, provide details on Page 6, Section 6. Principal Questionnaire - Page 2 of 13 Revised 1/92

3 7. NOTE: An affirmative answer is required below whether the sanction arose automatically, by operation of law, or as a result of any action taken by a government agency. In the past 5 years, have you and/or any affiliated businesses or not-for-profit organizations listed in Section 5 in which you have been a principal owner or officer: No Yes a. been debarred by any government agency from entering into contracts with that agency? If yes, provide details for each such instance on Page 7 and check Section 7A. No Yes b. been found not responsible by any government agency; and/or been a respondent before any type of New York City Board of Responsibility, and/or been the subject of a hearing before the New York City Office of Administrative Trials and Hearings (OATH); and/or is any such hearing now pending? If yes, provide details for each such instance on Page 7 and check Section 7B. No Yes c. been declared in default and/or terminated for cause on any contract, and/or had any contract cancelled for cause? If yes, provide details for each such instance on Page 7 and check Section 7C. No Yes d. been denied the award of a contract and/or the opportunity to bid on a contract, including, but not limited to, failure to meet pre-qualification standards? If yes, provide details for each such instance on Page 7 and check Section 7D. No Yes e. been suspended by any government agency from entering into any contract with it; and/or is any action pending that could formally debar or otherwise affect such business s ability to bid or propose on contracts? If yes, provide details for each such instance on Page 7 and check Section 7E. 8. No Yes Have any of the businesses or organizations listed in response to Question 5 filed a bankruptcy petition and/or been the subject of involuntary bankruptcy proceedings during the past 7 years, and/or for any portion of the last 7 year period, been in a state of bankruptcy as a result of bankruptcy proceedings initiated more than 7 years ago and/or is any such business now the subject of any pending bankruptcy proceedings, whenever initiated? If yes, provide details for each such instance on Page 7, Section 8. Principal Questionnaire - Page 3 of 13 Revised 1/92

4 9. No Yes a. Is there any felony charge pending against you? If yes, provide details for each such charge on Page 8 and check Section 9A. No Yes No Yes No Yes No Yes No Yes b. Is there any misdemeanor charge pending against you? If yes, provide details for each such charge on Page 8 and check Section 9B. c. Is there any administrative charge pending against you? If yes, provide details for each such charge on Page 8 and check Section 9C. d. In the past 10 years, have you been convicted, after trial or by plea, of any felony, or of any other crime, an element of which relates to truthfulness or the underlying facts of which related to the conduct of business? If yes, provide details for each such conviction on Page 8 and check Section 9D. e. In the past 5 years, have you been convicted, after trial or by plea, of a misdemeanor? If yes, provide details for each such conviction on Page 8 and check Section 9E. f. In the past 5 years, have you been found in violation of any administrative or statutory charges? If yes, provide details for each such occurrence on Page 8 and check Section 9F. 10. No Yes a. In addition to the information provided in response to Questions 7 through 9, in the past 5 years, have you been the subject of a criminal investigation and/or a civil anti-trust investigation by any federal, state or local prosecuting or investigative agency and/or the subject of an investigation where such investigation was related to activities performed at, for, or on behalf of the submitting business entity and/or an affiliated business listed in response to Question 5? If yes, provide details for each such investigation on Page 9, Section 10A. No Yes b. In addition to the information provided in response to Questions 7 through 9, in the past 5 years, has any business or organization listed in response to Question 5, been the subject of a criminal investigation and/or a civil anti-trust investigation and/or any other type of investigation by any government agency, including but not limited to federal, state, and local regulatory agencies while you were a principal owner or officer? If yes, provide details for each such investigation on Page 10, Section 10B. Principal Questionnaire - Page 4 of 13 Revised 1/92

5 11. No Yes In the past 5 years, have you or this business, or any other affiliated business listed in response to Question 5 had any sanction imposed as a result of judicial or administrative proceedings with respect to any professional license held? If yes, provide details for each such instance on Page 11, Section No Yes Do you presently serve, or have you within the past 5 years served as: an elected or appointed official or officer (do not, however, include positions in which you served solely as an unpaid member of one or more advisory committee(s) to a New York City agency); a full or part-time employee in a New York City agency with policy-making responsibility in your position; an officer of any political party or organization in New York City, whether paid or unpaid? If 'yes', provide details for each such instance on Page 11, Section No Yes For the past 5 tax years, have you failed to file any required tax returns or failed to pay any applicable federal, state or New York City taxes or other assessed New York City charges, including but not limited to water and sewer charges? If 'yes', provide details for each such year on Page 11, Section 13. Principal Questionnaire - Page 5 of 13 Revised 1/92

6 Section 3. Total percent of stock you hold Purchase date / / (If sole proprietorship, enter 100%) Section 4. Loan Amount Guarantee Amount Security Amount Lease Amount Amount (Other) Amount (Other) Section 5. Business name EIN For Profit Not-For-Profit Telephone Your title Address Affiliated from / / to / / Business name EIN For Profit Not-For-Profit Telephone Your title Address Affiliated from / / to / / Business name EIN For Profit Not-For-Profit Telephone Your title Address Affiliated from / / to / / Section 6. Business name EIN Business name EIN Business name EIN Principal Questionnaire - Page 6 of 13 Revised 1/92

7 Section 7. The following refers to Section: 7A 7B 7C 7D 7E Business name EIN Your title Date of Action: From / / to / / Agency Contract# Reason for action The following refers to Section: 7A 7B 7C 7D 7E Business name EIN Your title Date of Action: From / / to / / Agency Contract# Reason for action The following refers to Section: 7A 7B 7C 7D 7E Business name EIN Your title Date of Action: From / / to / / Agency Contract# Reason for action Section 8. Business name EIN Court Filing date / / Court address Index or docket number Date discharged / / Business name EIN Court Filing date / / Court address Index or docket number Date discharged / / Principal Questionnaire - Page 7 of 13 Revised 1/92

8 Section 9. The following refers to Section: 9A 9B 9C 9D 9E 9F Date of charges / / Court Court address Docket number Nature of charges Result of charges Date / / The following refers to Section: 9A 9B 9C 9D 9E 9F Date of charges / / Court Court address Docket number Nature of charges Result of charges Date / / The following refers to Section: 9A 9B 9C 9D 9E 9F Date of charges / / Court Court address Docket number Nature of charges Result of charges Date / / The following refers to Section: 9A 9B 9C 9D 9E 9F Date of charges / / Court Court address Docket number Nature of charges Result of charges Date / / Principal Questionnaire - Page 8 of 13 Revised 1/92

9 Section 10A. Agency Agency address Agency contact Telephone ( ) Date of investigation / / Nature of investigation Result of investigation Agency Agency address Agency contact Telephone ( ) Date of investigation / / Nature of investigation Result of investigation Agency Agency address Agency contact Telephone ( ) Date of investigation / / Nature of investigation Result of investigation Principal Questionnaire - Page 9 of 13 Revised 1/92

10 Section 10B. Business name EIN Agency Agency address Agency contact Telephone ( ) Date of investigation / / Nature of investigation Result of investigation Business name EIN Agency Agency address Agency contact Telephone ( ) Date of investigation / / Nature of investigation Result of investigation Business name EIN Agency Agency address Agency contact Telephone ( ) Date of investigation / / Nature of investigation Result of investigation Principal Questionnaire - Page 10 of 13 Revised 1/92

11 Section 11. Name EIN/SSN Date of hearing / / Court or Administrative tribunal Address of court/tribunal Index/docket or reference number Reason for Sanction Result of Sanction Date Section 12. Title in business City agency name Title in City agency Title in business City agency name Title in City agency Title in business City agency name Title in City agency Section 13. Taxes were not filed for tax years Taxes were not paid for tax years Explanation Principal Questionnaire - Page 11 of 13 Revised 1/92

12 CERTIFICATION A MATERIALLY FALSE STATEMENT WILLFULLY OR FRAUDULENTLY MADE IN CONNECTION WITH THIS QUESTIONNAIRE MAY RESULT IN RENDERING THE SUBMITTING BUSINESS ENTITY NOT RESPONSIBLE WITH RESPECT TO THE PRESENT BID OR FUTURE BIDS, AND, IN ADDITION, MAY SUBJECT THE PERSON MAKING THE FALSE STATEMENT TO CRIMINAL CHARGES. I,, being duly sworn, state that I have read and understand all the items contained in the foregoing 11 pages of this questionnaire and the following pages of attachments; that I supplied full and complete answers to each item therein to the best of my knowledge, information and belief; that I will notify the Agency in writing of any change in circumstances occurring after the submission of this questionnaire and before the execution of the contract; and that all information supplied by me is true to the best of my knowledge, information and belief. I understand that the City will rely on the information supplied in this questionnaire as additional inducement to enter into a contract with the submitting business entity. Sworn to before me this day of 19 Notary Public Name of submitting business by Print name Signature Title / / Date Principal Questionnaire - Page 12 of 13 Revised 1/92

13 AFFIDAVIT OF NO CHANGE Complete this affidavit only when a VENDEX Principal Questionnaire (revised January 1992) has been previously completed and submitted. (Check one) Type of Previous Submission: 1. Fully Completed Questionnaire 2. Changed Questionnaire If 2. checked, provide submission date of fully completed Questionnaire / / Business name EIN/SSN Address Current proposal/bid submitted to New York City Agency I,, Print name of, Print name of business entity affirm that the above referenced VENDEX Questionnaire was submitted to on New York City Agency Date and was true as signed, and that since the above date nothing has occurred which changed in any way any response to that Questionnaire. Sworn to before me this day of 19 Notary Public Submitted by Print Name Signature Title / / Date Principal Questionnaire - Page 13 of 13 Revised 1/92

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