att3_Experience_Questionnaire.pdf

Attachment 3

Westside Hiawatha N.F. CSE Services

EXPERIENCE AND CAPABILITY QUESTIONNAIRE

Instructions: See Box 10, REMARKS, if extra space is needed to answer any items below. Mark "X" in the appropriate boxes. Please list NA for inapplicable items.

1. Contractor's Name, Address & Telephone Number 2. Type of Business

____ Company

____ Corporation

____ Non-profit Organization

____ Co-partner ____ Individual

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

4. How many years of experience as a prime contractor? _________ subcontractor? ________

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

Contract Amount

Type of Project Date Completed

Name and Telephone Number to Contact For Information

6. List all of your firm's current contract commitments.

Contract Number

Contract Amount

Type of Project Est. Date of Completion

Name and Telephone Number to Contact For Information

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 Question 7a. or 7b., please specify location(s) and reason(s):

EXPERIENCE AND CAPABILITY QUESTIONNAIRE -- OMB Clearance Number 9000-

8. Organization that will be available for this project:

a. Minimum No. of employees: _______________ Maximum No. of employees: ________________

b. Are employees regularly on your payroll? ____ yes ___ no

c. If applicable, specify equipment available for this contract:

d. If applicable, estimate rate of progress (such as 2.0 acres per day):

Minimum progress rate: ___________________ Maximum progress rate: ____________________________

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

Individual's Name Present Position Years Experience Type of Work

10. Remarks, Additional Technical & Bio-based information if applicable:

CERTIFICATION: I certify that all of the statements made above 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.

Signature Title Date