Attachment_4_Experience_Questionnaire.docx

12455019R0005 Wastewater Vault Pumping Grandfather RD Attachment 4

EXPERIENCE QUESTIONNAIRE

Instructions: See Box 11, remarks, if extra space is needed to answer any item below. Mark X in the appropriate boxes.

1. Contractors Name, Address, Telephone No. & Email

2. Type of Business ___Company ___Co-Partner ___Non-profit

___Corporation ___Individual

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

4. How many years experience as a Prime Contractor___________ Subcontractor____________

5. List the projects your business has completed in the last 5 years from the solicitation issuance date

CONTRACT

NUMBER

AWARD

AMOUNT

COMPLETED

DATE CONTRACT

COMPLETED

6. Not Applicable Left Blank

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

7. If "yes" to either item 7a or 7b specify location(s) and reason(s) why

8. Organization information available for this project:

a. Minimum # of employees: ____________ and Maximum # of employees: ______________

b. Are employees regularly on your payroll: ___yes __ _no

c. Specify equipment available for this contract:

d. Estimate rate of progress:

e. Planning & Scheduling:

1. How do you intend to plan scheduling for other concurent projects.

f. Site Visit:

1. Have you visited the site and are you familiar with the work to be performed?

2. Please explain.

g. Safety & Traffic Control

1. Please explain the safety measures that you will put in place to ensure that site specific safety hazards have been considered adequate mitigation measures are in place for those hazards.

9. List the experience of the principal individuals of your business that will be used to perform this solicitation:

(Such as, motorgrader operator, other equipment operators, site superintendant, etc…)

10. Information required to complete a responsibility determination if the apparent successful offeror.

a. Credit References

b. Banking Information.

11. REMARKS

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:

Name: