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BID TITLE: BID 19 -17 -12 -HR <br />BID NUMBER: ROOFING MAINTENANCE & REPAIRS <br />SCHEDULE "D" <br />CITY OF SUNRISE <br />BIDDER'S QUALIFICATION STATEMENT <br />The undersigned certifies under oath the truth and correctness of all statements and all answers to <br />questions made hereinafter: <br />Company <br />Name: <br />Address: <br />Street City State Zip Code <br />Telephone:( ) Fax:( E - <br />Mail: <br />Web Site: <br />How many years has your organization been in business under its present name? Yes <br />If Bidder is operating under Fictitious Name, submit evidence of compliance with Florida Fictitious <br />Name Statute: <br />Under what former names has your business operated? <br />At what address was that business located? <br />Are You Certified? Yes No If Yes, ATTACH COPY OF LICENSE <br />Are You Licensed? Yes No If Yes, ATTACH COPY OF LICENSE <br />Has your company or its senior officers ever declared bankruptcy? <br />Yes No If yes, explain: <br />Are you a sales representative, distributor, broker, manufacturer <br />of the commodities/services bid upon? <br />Have you ever received a Contract or a Purchase Order from the City of Sunrise or other government <br />entity? Yes No If Yes, explain (date, service/project, bid title, <br />etc.) <br />Have you ever received a complaint on a Contract or bid awarded to you by any government entity? <br />Yes No if yes, explain: <br />Have you ever been debarred or suspended from doing business with any government entity? <br />Revised 6/27/18 Page 73 <br />