Attachment_4_Experience_and_Past_Performance_Questionnaire.pdf

Solicitation No. 12475619Q0010

Attachment 4

EXPERIENCE AND PAST PERFORMANCE QUESTIONNAIRE

Instructions: Use Item No. 10 Remarks if extra space is needed to answer any item below. Answer all items.

1. Contractor’s Name, Address & Telephone Number.

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

Subcontractor? _____ Years

5. List the projects your business has completed in the last three (3) years.

COMPANY NAME,

ADDRESS , TELEPHONE

NUMBER AND CONTACT

PERSON

CONTRACT TYPE/PROJECT

DESCRIPTION

CONTRACT

AMOUNT

PERIOD OF

PERFORMANCE/DATE

COMPLETED

1. List all of your firms’ current contract commitments.

CONTRACT

NUMBER

AWARD

AMOUNT

Contact Name, Address & Telephone

Number

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.

Solicitation No. 12475619Q0010

Attachment 4

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:

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

NAME PRESENT POSITION YEARS

EXPERIENCE

TYPE OF WORK

10. REMARKS

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

Duns # _______________

Tax ID# ______________