Atch 5 exp questionnaire.docx

Attachment 5

EXPERIENCE QUESTIONNAIRE

Instructions: See Box 9, remarks, if extra space is needed to answer any item below. Additional sheets may be attached.

1. Contractors Name, Address & Telephone No.

2. Type of Business __Company __Co-Partner __Non-profit __Corporation __Individual

3. How many years experience do you have in this line of work____Yrs

4. How many years experience as a prime contractor_____ subcontractor___

5. LIST OF PROJECTS YOUR BUSINESS HAS COMPLETED WITHIN THE LAST 3 YEARS

NOTE: The description of work performed should be in sufficient detail for the Government to determine what the work included. (i.e., what tasks were performed, (grounds maintenance, erosion control, mulching, forestry work performed, type of equipment used, special safety or requirements) Use of only a project title does not usually provide enough detail for the Government to make an evaluation.

Contract Number:______________________________________ Award Amount: _________________________________ Client/Company’s Name/Address: ________________________________________________________________________ Contact Name and Telephone number: ____________________________________________________________________ Description of Work Performed: _________________________________________________________________________ Date completed or scheduled for completion: ______________________________________________________________

Contract Number:______________________________________ Award Amount: _________________________________ Client/Company’s Name/Address: ________________________________________________________________________ Contact Name and Telephone number: ____________________________________________________________________ Description of Work Performed: _________________________________________________________________________

Date completed or scheduled for completion: ______________________________________________________________

Contract Number:______________________________________ Award Amount: _________________________________ Client/Company’s Name/Address: ________________________________________________________________________ Contact Name and Telephone number: ____________________________________________________________________ Description of Work Performed: _________________________________________________________________________

Date completed or scheduled for completion: ______________________________________________________________

Contract Number:______________________________________ Award Amount: _________________________________ Client/Company’s Name/Address: ________________________________________________________________________ Contact Name and Telephone number: ____________________________________________________________________ Description of Work Performed: _________________________________________________________________________

Date completed or scheduled for completion: ______________________________________________________________

Contract Number:______________________________________ Award Amount: _________________________________ Client/Company’s Name/Address: ________________________________________________________________________ Contact Name and Telephone number: ____________________________________________________________________ Description of Work Performed: _________________________________________________________________________ Date completed or scheduled for completion: ______________________________________________________________

6a. Have you ever failed to complete any work awarded to you? __yes __ no

6b. Has work ever been completed by performance bond? __yes __ no

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

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

8. Information required to complete a responsibility determination of the apparent successful offeror. (Additional information may be requested once a contractor is selected for award.. Moreover, the contractor might need to provide additional authorization from a creditor to grant access.)

a. Credit References

b. Banking Information.

9. REMARKS (Additional sheets may be attached to the experience questionnaire)

HERBICIDE LICENSE #__________________ CATEGORY: _______________ STATE_______________

EXPIRATION DATE:_______________

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: