HomeMy WebLinkAboutAnnual List 2023 PreQualification ApplicationCity of Palm Desert
Pre-Approved Vendor List Application
Page | 1
CITY OF PALM DESERT
REQUEST FOR STATEMENT OF QUALIFICATIONS
FOR “PRE-APPROVED VENDOR LIST” OF SERVICES AND GOODS
REGULARLY REQUIRED BY THE CITY OF PALM DESERT.
NOT FOR CONSTRUCTION OR CONSTRUCTION-RELATED SERVICES
73510 Fred Waring Drive, Palm Desert, CA 92260
Please email completed form to rtrupiano@palmdesert.gov
City of Palm Desert
Pre-Approved Vendor List Application
Page | 2
PRE-QUALIFICATION APPLICATION; PRE-APPROVED VENDOR LIST
The undersigned Applicant requests that the City of Palm Desert (“City”) consider a request to be placed
on a list of authorized vendors for goods and/or services required by the City.
1.Applicant Information. Complete the following to provide information about the Applicant.
Firm/Company Name
____________________________________________________
Physical Office
Location _____________________________________________________
(Address)
_____________________________________________________
(City, State and Zip Code)
Mailing Address (if
different from physical
office address)
_____________________________________________________
(Address)
_____________________________________________________
(City, State and Zip Code)
Applicant Contacts ____________________________
(Name)
____________________________
(Phone)
____________________________
(email)
____________________________
(Name)
____________________________
(Phone)
____________________________
(email)
Type of Business Sole Proprietorship
Partnership/S Corporation
LLC
Corporation
Business Date of
Inception _________________________________________
NAICS Business
Classification(s)
2.Pre-Qualification. The Applicant requests to be pre-qualified for regular and occasional needs for the
provision of products and/or services.
3. Applicant Business Description. Please describe the nature of the services or goods offered by
your business.
[CONTINUED NEXT PAGE]
City of Palm Desert
Pre-Approved Vendor List Application
Page | 3
4. Applicant Insurance. Complete the following for the Applicant’s current General Liability Insurance
and Workers Compensation Insurance.
General Liability
Insurance
Insurer: __________________________
Policy No. _________________________
Broker _________________________
__________________________
(Liability Insurance Broker Contact Name)
__________________________________
(Street Address)
__________________________________
(City, State & Zip Code)
(____) ____________ (____) _________
Telephone Fax
_________________________________
Email address
Coverage Limits:
Per Occurrence:
____________________________
Dollars ($_________)
Aggregate:
____________________ Dollars
($__________)
Workers
Compensation
Insurance
Insurer: _________________________________
Policy No. _________________________________
Broker __________________________________
_____________________________________________________
(Broker Contact Name)
_____________________________________________________
(Street Address)
_____________________________________________________
(City, State & Zip Code)
(______) __________________ (______) ___________________
Telephone Fax
____________________________________________
(Email address)
Automobile
Liability
Insurance
(Required if firm
staff are
required to
drive in the
normal course
of providing
services to the
City).
Insurer: __________________________
Policy No. _________________________
Broker _________________________
__________________________
(Insurance Broker Contact Name)
__________________________________
(Street Address)
__________________________________
(City, State & Zip Code)
(____) ____________ (____) _________
Telephone Fax
_________________________________
(Email address)
[CONTINUED NEXT PAGE]
City of Palm Desert
Pre-Approved Vendor List Application
Page | 4
5. References. Complete the following to identify Applicant’s references.
Current Customer References
Firm Name Address Contact Person Contact information
_____________________________
______________________________________
(Street Address)
______________________________________
(City, State and Zip Code)
_______________________________
_______________________________
(Contact Phone Number)
________________________________
(Contact email)
_____________________________
______________________________________
(Street Address)
______________________________________
(City, State and Zip Code)
_________________________
_______________________________
(Contact Phone Number)
________________________________
(Contact email)
_____________________________
______________________________________
(Street Address)
______________________________________
(City, State and Zip Code)
_______________________________
_______________________________
(Contact Phone Number)
________________________________
(Contact email)
City of Palm Desert
Pre-Approved Vendor List Application
Page | 5
6. Supplemental Questions. An Applicant will not be pre-qualified if the response to any of the
following essential questions results in a “Not Qualified” designation.
6.1. The Applicant possesses valid license(s) or certificate(s) where required for the services
offered.
☐ Yes ☐ No (Not Qualified) ☐ Not Applicable.
6.2. Does the Applicant possess a valid business license with any jurisdiction within the
Coachella Valley? (Local preference determination)
☐ Yes ☐ No
6.3. Applicant maintains a commercial general liability insurance policy with a coverage
amount of at least $1,000,000 per occurrence and $2,000,000 in the aggregate.
☐ Yes ☐ No (Not Qualified)
6.4. Applicant maintains an automobile liability insurance policy with a coverage amount of
at least $1,000,000.
☐ Yes ☐ No (Not Qualified) ☐ Not Applicable.
6.5. Applicant has a current workers’ compensation insurance policy as required by the Labor
Code or is legally self-insured pursuant to Labor Code § 3700.
☐ Yes ☐ No (Not Qualified)
☐ Applicant is exempt from this requirement because it has no employees.
6.6. The Applicant is ineligible or debarred from any public agency.
☐ Yes (Not Qualified) ☐ No
6.7. During the past three (3) years, the Applicant or any predecessor to the Applicant, or any
of the equity owners of the Applicant been convicted of a federal or state crime involving
fraud, theft, or any other act of dishonesty.
☐ Yes (Not Qualified) ☐ No
6.8. The Applicant’s Worker’s Compensation Insurance prior five (5) year average
Experience Modification Rating (“EMR”) rating over the past five (5) years is more than
1.5.
☐ Yes (Not Qualified) ☐ No
6.9. The Applicant’s Worker’s Compensation Insurance current average Experience
Modification Rating (“EMR”) rating is more than 1.5.
☐ Yes (Not Qualified) ☐ No
6.10. CAL OSHA or OSHA has cited and assessed penalties against the Applicant for “serious
and willful” or “repeat” violations of its safety or health regulations in the past five (5)
years.
☐ Yes (Not Qualified) ☐ No
City of Palm Desert
Pre-Approved Vendor List Application
Page | 6
7.Statement of Capabilities. Please provide information on the unique qualifications or capabilities
of your firm.
8.Standard Pricing Information. Please upload as an attachment any pricing sheets for your
standard rates.
9.Authority and Certification. The undersigned is duly authorized to execute this Pre-Qualification
Application under penalty of perjury on behalf of the above-identified Applicant. The undersigned
warrants and represents that he/she has personal knowledge of each of the responses to this Pre-
Qualification Application and/or that he/she has conducted all necessary and appropriate inquiries
to determine the truth, completeness and accuracy of responses to this Pre-Qualification
Application. The undersigned declares and certifies that the responses to this Pre-Qualification
Application are complete and accurate; there are no omissions of material fact or information that
render any response to be false or misleading; and there are no misstatements of fact in any of the
responses. The Applicant acknowledges and agrees that if the City determines that any response
herein is false or misleading or contains misstatements of fact, the Applicant will not be deemed
qualified to participate in the City’s Informal Bidding procedures.
Submitted this ___ day of ________________, 20___ at ____________________________________.
(City and State)
I declare under penalty of perjury under California law that the foregoing is true and correct.
By: _____________________________
Title: _____________________________