12475620R0001 Attachment 7 - Experience Questionnaire.pdf

12475620R0001, Grays Branch Culvert Replacement, Ocoee Ranger District Attachment 7 - Page 1 of 2

ATTACHMENT 7 –EXPERIENCE QUESTIONNAIRE

Instructions: See Box 8, 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____Years

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.

culvert removal/installation, subgrade repair and road work.) List the services performed and quantities involved (miles, linear feet) or other similar work accomplished).

Use of only a project title does not usually provide enough detail for the Government to make an evaluation.

Project & Location ______________________________________________________________________________________________

Contract Number:_______________________________ Award Amount: ________________________________________________

Period of Performance and/or completion date: ________________________________________________________________________

Client/Company’s Name/Address: __________________________________________________________________________________

Contact Name, email and Telephone number:

Description of Services (refer to note in No. 5 type of culvert removal/installation, subgrade repair and road work, etc.)

Project & Location ______________________________________________________________________________________________

Contract Number:_______________________________ Award Amount: ________________________________________________

Period of Performance and/or completion date: ________________________________________________________________________

Client/Company’s Name/Address: __________________________________________________________________________________

Description of Services (refer to note in No. 5 type of asphalt, paving, resurfacing, subgrade repair etc.)

Project & Location ______________________________________________________________________________________________

Contract Number:_______________________________ Award Amount: ________________________________________________

Period of Performance and/or completion date: ________________________________________________________________________

Client/Company’s Name/Address: __________________________________________________________________________________

Contact Name, email and Telephone number: ________________________________________________________________________

Description of Services (refer to note in No. 5 type of asphalt, paving, resurfacing, subgrade repair etc.)

12475620R0001, Grays Branch Culvert Replacement, Ocoee Ranger District Attachment 7 - Page 2 of 2

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 6a or 6b specify location(s) and reason(s) why

7. Information required to complete a responsibility determination, if necessary, 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

Company Name/Address Point of Contact Telephone number Materials/Services Provided

b. Banking Information.

Company Name/Address Point of Contact Telephone number Account No.

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

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: Title: 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: Title: Date:

ATTACHMENT 4 –Experience Questionnaire