Contractor Pre-Qualification Form

Jorge Chavez International Airport Expansion Proyect-newLIM

APPLICANTS INFORMATION

LEGAL ENTITY NAME   WEBSITE ADDRESS  

DOING BUSINESS AS   STOCK EXCH | TICKER

MAILING ADDRESS   DATE ESTABLISHED

CITY, STATE & ZIP CODE   YEARS IN BUSINESS  

PHYSICAL ADDRESS   FEDERAL TAX ID NO.  

CITY, STATE & ZIP CODE   DUNS | RUT | RUC NO.  

OTHER ADDRESS   CONTRACTOR LIC NO.  

CITY, STATE & ZIP CODE   OSHA | MSHA NO.  

BUSINESS TYPE(S)   Sole Proprietorship   Partnership   Corporation   S Corporation

(CHECK ALL THAT
APPLY)   Limited Liability Company (LLC)

COUNTRY OF CONSTITUTION/INCORPORATION  

CONTACTS NAME, TITLE   PHONE   EMAIL

PRIMARY CONTACT    
 
SECONDARY CONTACT    
 

JV / Consortium NAME , TITLE   % OWNED   TIME WITH COMPANY

SIGNIFICANT OWNER    
 
SIGNIFICANT OWNER    
 
SIGNIFICANT OWNER    
 

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HEALTH, SAFETY & ENVIRONMENTAL FACTORS

1. Do you have an HSE policy?

Yes (attach or detail below) No Find out more below
Additional information:

1. Do you have Management Systems approved by senior management to proactively manage Health and Safety
within your organization? (If yes, please indicate: Scope, List of the main components/elements, international
standards that the System Management is aligned with, copy of certificates
Yes No Find out more below
Additional information:

2. Do you have a procedure to ensure that health and safety risks are properly assessed and controlled prior to
the start of the works?

Yes, (attach procedure and risk record) No Find out more below
Additional information:

3. Do you have performance outcome indicators?

Yes No Find out more below

Present Year Last Year before last

2020 year2019 2018

Man hours worked per year

Number of fatalities
Number of cases with lost working days (Lost
Time Injuries)
Number of restrictive work injuries
Number of injuries with medical treatment
Man hours performed during the year
Total frequency of registration injuries
Number of environmental incidents
Additional information: See Appendix HSEC (Form)

4. Do you have preventive performance indicators of Health and Safety?

Yes (please attach examples) No Find out more below
Additional information

5. Have you received any charges and/or fines within the last two years on HSE-related issues? (If yes, provide a
brief summary of the case and the results.
Yes No Find out more below

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Additional information

6. Do you have incident/accident reporting procedures and an accident investigation method?

Yes (provide details of KPIs) No Find out more below
Additional information:

7. Does your team receive safety training?

Yes (please detail what and how often) No Find out more below
Additional information

8. Do you have control inspection procedures or to verify compliance with H&S requirements?
Yes (please, detail) No Find out more below
Additional information

9. Has Health and Safety responsibilities been clearly defined for managers, supervisors and workers?
Yes No
Additional information

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SAFETY RATES

LAST 12 MONTHS LAST 24 MONTHS LAST 36 MONTHS

WORKER’S COMP EXPERIENCE MODIFICATION

 
RATE (EMR)
LOST TIME INJURY RATE (LTIR)      

TOTAL RECORDABLE INJURY RATE (TRIR)  

TOTAL INJURY RATE (TIR)      

TOTAL NUMBER (#) OF FATALITIES  

TOTAL EMPLOYEE HOURS (HRS)      

NON-PERFORMING CONTRACTS
Contract
Year Non-Conformance Outcome
Value
       

       

QUALITY MANAGEMENT
1. . Do you have a formal QA/QC system?
Yes (please, detail) No Find out more below
Additional information ->

11. . Is the quality control and quality control system documented?

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Yes (please, detail) No Find out more below

Additional Information ->

12. . Do you have dedicated quality inspection/quality control staff?

Yes (please, detail) No Find out more below
Additional information ->

13. . Are records of inspections and tests or other QA/QC activities maintained?
Yes (please, detail) No Find out more below
Additional information ->.

14. . Do you perform quality audits?

Yes (please, detail) No Find out more below
Additional information ->

SOCIAL RESPONSABILITY

Do you have Management Systems approved by Senior Management to proactively manage Social
1 Responsibility within your organization?
Yes (if yes provide certificates, policies) No Find out more below
Additional information

2. Do you have mechanisms in place to prevent discrimination in any of its forms?

Yes (please, detail) No Find out more below
Additional information

Strategies are carried out to ensure the health and safety of workers, contemplating the implementation of
3. occupational health and industrial safety programmes, in agreementor with the provisions of the Law?
Yes (please, detail) No Find out more below
Additional information

Do you have policies to prevent bribery and corruption in any of its forms?
Yes (please, detail) No Find out more below
Additional information

Do you have adequate communication channels to identify and correct risks and corruption situations?
Yes (please, detail) No Find out more below
Additional information

Actions are implemented to ensure transparency in paperwork, donations, sponsorships, gifts and
representation expenses?

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 Contractor Pre-Qualification Form

Yes (please, detail) No Find out more below

Additional information

Actions are taken to ensure the promise of sale, the proper response to complaints and complaints and after-
sales service for customers, users and / or consumers taking into account the expectationsof them?
Yes (please, detail) No Find out more below
Additional information

Do you carry out actions that promote the generation of constructive relationships between the communities of
the area of influence and the impact of your operations?
Yes (please, detail) No Find out more below
Additional information

COMMUNITY RELATIONS

1. 1 Do you have a responsible person and designated for Community Relations?

Yes (please, detail) No Find out more below
Additional information ->

Do you currently have or have had experience in local employment procedures with communities in recent
years?
Yes (please, detail) No Find out more below
Additional information ->

Do you currently have or have had experience in procurement procedures for goods and/or services
with communities in recent years?
Yes (please provide) No Find out more below
Additional information:

Do you currently have or have had in recent years the design and implementation of Social Responsibility
projects in communities?
Yes (please, detail) No Find out more below
Additional information

Additional information

FINANCIAL SITUATION
Financial information in US$   Historic information for previous ( 3 ) years
equivalent (US $ equivalent in 000s)

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Year 1 Year 2 Year 3 Year … Year n

Information from Balance Sheet

Total Assets (TA)          

Total Liabilities (TL)          

Net Worth (NW)          

Current Assets (CA)          

Current Liabilities (CL)          

Information from Income Statement

Total Revenue (TR)          

Profits Before Taxes (PBT)          

Attached are copies of financial statements (balance sheets, including all related notes, and income statements) for the years
required above complying with the following conditions:

a)     Must reflect the financial situation of the Bidder or party to a JV, and not sister or parent companies

b)    Historic financial statements must be audited by a certified accountant

c)     Historic financial statements must be complete, including all notes to the financial statements

d)    Historic financial statements must correspond to accounting periods already completed and audited (no
statements for partial periods shall be requested or accepted)

RISK MANAGEMENT SITUATION

1. Has the Applicant been declared ineligible for funding by any bank?   YES   NO

2. Has the Applicant had any full settled litigation?   YES   NO

3. Has Applicant failed to complete any awarded work within the last 5 years?   YES   NO

4. Has Applicant been terminated or dismissed from any contract within the last 5
  YES   NO
years?

5. Does Applicant have any pending litigation? (please provide relevant details)   YES   NO
6. Has Applicant had liquidated damages assessed against it on any project within the
  YES   NO
last 3 years?

COMPLIANCE
YE
1. The Applicant has reviewed and acknowledges compliance with LAP Policy.     NO
S

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 Contractor Pre-Qualification Form

YE
2. The Applicant has a Compliance System.     NO
S

AVERAGE ANNUAL CONSTRUCTION TURNOVER

Annual turnover data (construction only)
US$
Year Amount and Currency
Equivalent
     
     
     
     
 

*Average Annual Construction

Turnover
*Average annual construction turnover calculated as total certified payments received for work in progress or
completed, divided by the number of years

GENERAL CONSTRUCTION EXPERIENCE (massive earthwork, asphalt, concrete, buildings, Mechanical

Electrical and Special System, metals structures)
Starting Ending Role of
  Month/Year*
 
Month/ Year
  Contract Identification  
Applicant
  Contract Name:  
Brief Description of Work
   
Performed by the Bidder:

      Name of Company:    

  Address of Company:  

 
           Contract Amount        

          Contract Name:      

Brief Description of Work

   
Performed by the Bidder:

      Name of Company:    

  Address of Company:  
 
          Contract Amount          

        Contract Name:      

Brief Description of Work

   
Performed by the Bidder:

      Name of Company:    

  Address of Company:  
                     

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Contract Amount:

          Contract Name:      

Brief Description of Work

   
Performed by the Bidder:

      Name of Company:    

  Address of Company:  

                   
  Contract Amount:

          Contract Name:      

Brief Description of Work

   
Performed by the Bidder:

      Name of Company:    

  Address of Company:  
                   
  Contract Amount:

          Contract Name:      
Brief Description of Work
   
Performed by the Bidder:

      Name of Company:    

  Address of Company:  
 
          Contract Amount          

* List calendar year starting with the earliest year.

SPECIFIC CONSTRUCTION EXPERIENCE (Runway and taxiway, airport control towers, airport special systems,
terminal buildings and ancillary facilities)
Similar Contract Number: ____
Information
of ____ required
Contract Identification  

Award Date  

Completion Date  

Management
Role in Contract Contractor
Contractor
Subcontractor

Total contract amount   US$

If party in a JV or subcontractor,
specify participation of total % US$
contract amount
Address:  

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 Contractor Pre-Qualification Form

Telephone/Fax Number:  

E-mail:  

Description of the similarity in

accordance with scope of works:
1. Amount  

2. Physical Size  

3. Complexity  

4. Methods/Technology  

5. Other Characteristics  

SPECIFIC DESIGN EXPERIENCE

Starting Ending Role of
  Month/Year*
 
Month/ Year
  Contract Identification  
Applicant
  Contract Name:  
Brief Description of Work
   
Performed by the Bidder:

      Name of Company:    

  Address of Company:  

 
           Contract Amount        

          Contract Name:      

Brief Description of Work

   
Performed by the Bidder:

      Name of Company:    

  Address of Company:  
 
          Contract Amount          

        Contract Name:      

Brief Description of Work

   
Performed by the Bidder:

      Name of Company:    

  Address of Company:  
 
          Contract Amount:          

          Contract Name:      

Brief Description of Work

   
Performed by the Bidder:

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 Contractor Pre-Qualification Form

      Name of Company:    

  Address of Company:  

 
          Contract Amount:          

          Contract Name:      

Brief Description of Work

   
Performed by the Bidder:

      Name of Company:    

  Address of Company:  
 
          Contract Amount:          

          Contract Name:      
Brief Description of Work
   
Performed by the Bidder:

      Name of Company:    

  Address of Company:  
 
          Contract Amount          

* List calendar year starting with the earliest year.

REFERENCES

COMPANY, NAME   PHONE   EMAIL

 
1. FINANCIAL INSTITUTION      

2. FINANCIAL INSTITUTION      

3. CLIENTS/OWNERS      

4. CLIENTS/OWNERS      

5. SUB-CONTRACTOR      

6. SUB-CONTRACTOR      

RECENT / CURRENT
PROJECT DESCRIPTION CONTRACT VALUE & TERM
PROJECTS & LOCATION

1.   US$

      YRS   MTHS

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 Contractor Pre-Qualification Form

2.   US$

      YRS   MTHS

APPLICATION TERMS AND CONDITIONS

Please mark one (1) response to each of the following statements, in consideration of Supplier’s pre-qualification:
1. Applicant is positioned to accept and successfully complete new projects within the YES NO
schedule as defined by the Company.    
2. Applicant will permit Company to visit Supplier’s location(s) for auditing or YES NO
expediting purposes as defined by the Company.    
3. Applicant authorizes Company to directly contact any and all references reported YES NO
herein    
4. Applicant agrees that participation in any Company bid process is at Supplier’s sole YES NO
expense.    
5. Applicant agrees that Company is not obligated to hire or contract with Supplier. YES NO
   
Thank you for completing this Qualification Form! Please attach current Rate Schedules and any other
requested information. If your company, product, or services are of interest to us, we will contact you with
further instructions.

APPLICANT’S AUTHORIZED REPRESENTATIVE(S)

The undersigned legal representative authorizes the Company to check financial references as necessary
through the provided trade references, bank references, credit-reporting agencies, and all other legally
acceptable means.
SIGNATURE   SIGNATURE  

PRINTED NAME   PRINTED NAME  

TITLE   TITLE  

DATE   DATE  

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