11.ATTACHMENT 3 - 36C25625Q0722 RELEVANT EXPERIENCE FORM.pdf
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- Solicitation number
- 36C25625Q0722
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The document is a Relevant Experience Form for a federal contract opportunity (Solicitation Number 36C25625Q0722) for Durable Medical Equipment (DME) and Home Medical Equipment (HME) services at the Michael E. DeBakey VA Medical Center in Houston, Texas. The form provides three template sections for contractors to document their previous contract experience, including details such as customer name, contract term, contract value, contact information, and scope of work, with space for up to three separate contracts.
This is a Total Small Business set-aside solicitation for a five-year Indefinite Delivery Contract with a Firm-Fixed Price, using NAICS code 621610 (Home Health Care Services) and a small business size standard of $19,000,000. Quotes are due by 11:59 PM Central Standard Time on April 25, 2025, and must be submitted via email to the Contract Specialist, Jeneice Matthews. The government will award to the lowest-price technically acceptable offeror, with requirements including current SAM registration and SBA small business certification.
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36C25625Q0722
ATTACHMENT A
RELEVANT EXPERIENCE FORM
Please list your contracts in the chronological order beginning with the most recent one. Contracts listed cannot be more than 5 years old. You can list ongoing contracts that began more than 5 years ago.
Contract #1
1. Customer Name 2. Customer’s Address
3. Name and Title of Contact Point 4. Contact Point’s Email Address
5. Contact Point’s Phone Number 6. Estimated Contract Value
7. Contract Term (Month and Year)
From _______ through _______________
8. Contract Effective Date
9. Contract Status
___Ongoing ___Completed
10. Scope of Contract Requirements (Describe in details the scope of works performed under this contract as indicated in the Request
For Quote documents. Attach separate sheet if additional space is needed.)
Contract #2
1. Customer Name 2. Customer’s Address
3. Name and Title of Contact Point 4. Contact Point’s Email Address
5. Contact Point’s Phone Number 6. Estimated Contract Value
9. Contract Status
___Ongoing ___Completed
10. Scope of Contract Requirements (Describe in details the scope of works performed under this contract as indicated in the Request
Contract #3
1. Customer Name 2. Customer’s Address
3. Name and Title of Contact Point 4. Contact Point’s Email Address
5. Contact Point’s Phone Number 6. Estimated Contract Value
9. Contract Status
___Ongoing ___Completed
10. Scope of Contract Requirements (Describe in details the scope of works performed under this contract as indicated in the Request
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