A21_Misc_past_performance.pdf

ATTACHMENT 1 Solicitation # 0040390805 page 1 of 3

PAST AND PRESENT PERFORMANCE SURVEY

Your Company Name:

Street Address:

City, State and ZIP Code:

1. GENERAL BUSINESS INFORMATION

Date Firm Organized/Established:

Company President: Vice President:

Dun & Bradstreet Number: __

Is company a; Partnership [ ] Separate entity [ ] Division [ ] N/A [ ]

2. CONTRACTS/SUBCONTRACTS COMPLETED OR IN PROGRESS

Complete and submit the information requested on page 2-3 below on prime contracts or subcontracts completed or in progress. Government contracts are preferred; but, if you have not performed Government contracts, indicate any other contracts completed or in progress.

ATTACHMENT 1 Solicitation # 0040390805 page 2 of 3

a. First Contract:

Contracting Agency or Company:

Point of Contact: Telephone Number:

Contract Number: Contract/Subcontract Amount: $

Location:

General Scope of Project:

Your Role (Prime [ ], Joint Venture [ ], or Subcontractor [ ]) and the work your firm performed:

Contract State Date: ___________________________

Contract Completion Date:

b. Second Contract:

Point of Contact: Telephone Number:

Project Title and Location:

Your Role (Prime [ ], Joint Venture [ ], or Subcontractor [ ]) and the work your firm performed:

Contract State Date: _______________________

ATTACHMENT 1 Solicitation # 0040390805 page 3 of 3

c. Third Contract:

Point of Contact: Telephone Number:

Project Title and Location:

Your Role (Prime [ ], Joint Venture [ ], or Subcontractor [ ]) and the work your firm performed:

Contract State Date: _______________________

4. Certification of Past and Present Performance Information:

Type or Print Information

Name of Survey Preparer _______________________________Phone:_________________

E-Mail;___________________________

Title__________________________________________

Signature______________________________________

Date__________________________________________