12445122R0007 - Construction Experience Questionaire Fillable.pdf

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Repair Trail Abutments Compartment 57
Solicitation number
12445122R0007
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Solicitation No: 12445122R0007

Repair Trail Abutments Compartment 57

Source Selection Information ‐ See FAR 2.101, 3.104 and 15.101‐2 For Official Use Only

APPENDIX D: Construction Experience Questionnaire

Repair Trail Abutments Compartment 57 Solicitation 12445122R0007

Construction Experience Questionnaire (to be completed by contractor)

Instructions: Do not alter the form, except for expanding the individual response blocks. The total length for each project data sheet shall not exceed three (3) double-sided 8.5” x 11”pages and shall be Times New Roman 11 font (minimum). Use Box 10 Remarks if extra space is needed to answer any item below.

Answer all items.

1. Contractor’s Name, Address & Telephone #. 2. Type of Business

___Company ___Co-Partner ___Corporation ___Individual ___Non-profit Organization

3. How many years’ experience do you have in this line of work? ______ years

4. How many years’ experience as a prime contractor? ______ years

And as a subcontractor? ______ years

5. List the projects/contracts your business has completed in the last five (5) years.

CONTRACT

AMOUNT

TYPE OF CONTRACT DATE

COMPLETED

Contact Name, Address and Tele. #

Source Selection Information ‐ See FAR 2.101, 3.104 and 15.101‐2 For Official Use Only

6. List all of your firms’ current contract commitments

CONTRACT

NUMBER

AWARD

AMOUNT

Contact Name, Address & Tele. #

Percent Completed

Date Contract Completed

7a. Have you ever failed to complete any work awarded to you? ___yes ___no 7b. Has work ever been completed by performance bond? ___yes ___no

7c. If “yes” to either item 7a or 7b above, specify reason(s) and location(s) why.

8. Organization structure that will be available for this project:

a. Minimum No. of employees: _____ and Maximum No. of employees: _____

b. Are employees regularly on your payroll? ___yes ___no

c. Specify equipment available for this contract:

d. Estimate rate of progress (exp. 100 feet, 1/8 mile a day, etc.):

Minimum progress rate: ____________ Maximum progress rate:____________

9. List the experience of the principal individuals of your business

NAME PRESENT POSITION YRS

EXP.

TYPE OF WORK

Source Selection Information ‐ See FAR 2.101, 3.104 and 15.101‐2 For Official Use Only

10. REMARKS

Duns#_______________ Tax ID#______________

CERTIFICATION: I certify that all of the statements made by me are complete and correct to be 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.

Signature Print or Typed Name Title Date

1 Contractors Name Address Telephone:
3 How many years experience do you have in this line of work years:
undefined:
years:
years_2:
CONTRACT AMOUNTRow1:
TYPE OF CONTRACTRow1:
DATE COMPLETEDRow1:
Contact Name Address and Tele Row1:
CONTRACT AMOUNTRow2:
TYPE OF CONTRACTRow2:
DATE COMPLETEDRow2:
Contact Name Address and Tele Row2:
CONTRACT AMOUNTRow3:
TYPE OF CONTRACTRow3:
DATE COMPLETEDRow3:
Contact Name Address and Tele Row3:
CONTRACT AMOUNTRow4:
TYPE OF CONTRACTRow4:
DATE COMPLETEDRow4:
Contact Name Address and Tele Row4:
CONTRACT AMOUNTRow5:
TYPE OF CONTRACTRow5:
DATE COMPLETEDRow5:
Contact Name Address and Tele Row5:
CONTRACT AMOUNTRow6:
TYPE OF CONTRACTRow6:
DATE COMPLETEDRow6:
Contact Name Address and Tele Row6:
CONTRACT NUMBERRow1:
AWARD AMOUNTRow1:
Contact Name Address Tele Row1:
Percent CompletedRow1:
Date Contract CompletedRow1:
CONTRACT NUMBERRow2:
AWARD AMOUNTRow2:
Contact Name Address Tele Row2:
Percent CompletedRow2:
Date Contract CompletedRow2:
7c If yes to either item 7a or 7b above specify reasons and locations why 1:
7c If yes to either item 7a or 7b above specify reasons and locations why 2:
7c If yes to either item 7a or 7b above specify reasons and locations why 3:
7c If yes to either item 7a or 7b above specify reasons and locations why 4:
a Minimum No of employees:
and Maximum No of employees:
Specify equipment available for this contract 1:
Specify equipment available for this contract 2:
Minimum progress rate:
Maximum progress rate:
NAMERow1:
PRESENT POSITIONRow1:
YRS EXPRow1:
TYPE OF WORKRow1:
NAMERow2:
PRESENT POSITIONRow2:
YRS EXPRow2:
TYPE OF WORKRow2:
NAMERow3:
PRESENT POSITIONRow3:
YRS EXPRow3:
TYPE OF WORKRow3:
NAMERow4:
PRESENT POSITIONRow4:
YRS EXPRow4:
TYPE OF WORKRow4:
NAMERow5:
PRESENT POSITIONRow5:
YRS EXPRow5:
TYPE OF WORKRow5:
CERTIFICATION I certify that all of the statements made by me are complete and correct to be best of:
Tax ID:
Print or Typed Name:
Title:
Date:
Check Box1: Off
Check Box2: Off
Check Box3: Off
Check Box4: Off
Check Box5: Off
Check Box6: Off
Check Box7: Off
Check Box8: Off
Check Box9: Off
Text10:

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