ExperienceQuestionnaire.docx

USDA Forest Service (3/03)

EXPERIENCE QUESTIONNAIRE

Instructions: See Box 11, Remarks, if extra space is needed to answer any item below. Mark “x” in appropriate boxes.

1. Contractor Name, Address, and Telephone Number

2. Submitted to (Office Name & Address)

3. Business

· Company Partnership

· Corporation Individual

· Non-profit Organization

4. How many years do you or your firm have in the line of work contemplated by this solicitation?

5. Years of Experience: How many years experience in contracting have you or your business had as a (a) prime contractor ________ and/or (b) sub-contractor ______?

6. Relevant Experience/Past Performance: List below the projects your business has completed within the last three years which are similar to this solicitation and the names of individuals who can comment on your performance of the work:

Contract Amount

Type of Project and Name of Business/Government Agency

Date Completed Name and Telephone No. of Owner/Person to Contact for Peformance Information

7. Concurrent Contractual Commitments: List below all of your firm’s contractual commitments running concurrently with the work contemplated by this solicitation:

Contract Amount

(Units) Percent Completed Date Contract Completed

8a. Have you ever failed to complete any work awarded to you? _____ Yes _____ No 8b. If “Yes” to either item 8a or 8b specify location(s) and reason(s) why:

9. Organization and Work Plan available for this project:

a. (1) Minimum number of employees:__________ and a (2) Maximum number of employees:__________

b. Are employees regularly on your payroll? _____ Yes _____ No

c. List personnel assigned to perform cone collection at the work site, and their experience to meet the Government Requirements (see block 10).

d. Specify equipment available for this contract:_______________________________________________

e. Estimate rate of progress below (such as bushels/day):

(1) Minimum progress rate: __________ and (2) Maximum progress rate: __________

f. Subcontractor:

(1) Name: (2) Experience: (3) % of work to be completed by sub:

10. Employee’s Relevant Experience: List below the relevant experience of the principal individuals of your business.

CERTIFICATION

I certify that all of the statements made by me are complete and correct to the best of my knowledge and that any persons named as references are authorized to furnish the Forest Service with any information needed to verify my capability to perform this project.

12a.Certifying Official’s Name and Title