Attachment_4_-_Experience_Questionnaire.pdf

United States

Department of Agriculture

Forest Service

Job Corps

Acquisition Management

1617 Cole Blvd., Bldg 17, Lakewood, CO 80401

Previous edition is obsolete Page 1 of 2 FS-6300-27 (3/00)

USDA – Forest Service

EXPERIENCE QUESTIONNAIRE

(Ref. FSH 6309.31 and 41 USC 1)

INSTRUCTIONS: See Box 11, Remarks, if extra space is needed to answer any questions below. Mark “X” in appropriate boxes.

1. CONTRACTOR NAME, ADDRESS, PHONE NO., AND DUNS NO.

2. SUBMITTED TO (Office Name and Address) 3. BUSINESS

Company Co-partnership

Corporation Individual

Non-profit Organization

4. How many years do you or your firm have in the line of work contemplated by this solicitation?

5. How many years of experience in contracting have you or your business had as a (a) prime contractor ____ and/or (b) sub-contractor ____?

6. List below the projects your business has completed within the last six years:

CONTRACT

AMOUNT

TYPE OF PROJECT

DATE

COMPLETED

NAME, ADDRESS, AND TELEPHONE NO. OF

OWNER/PERSON TO CONTACT FOR PROJECT

INFORMATION

7. List below all of your firm’s contractual commitments running concurrently with the work contemplated by this solicitation:

CONTRACT

NUMBER

DOLLAR AMT.

OF AWARD

NAME, ADDRESS, AND TELEPHONE NO. OF

BUSINESS/GOVERNMENT AGENCY INVOLVED

AWARDED

(Units)

PERCENT

COMPLETED

DATE CONTRACT

COMPLETED

8a. Have you ever failed to complete any work awarded to you? Yes No

8b. Has work ever been completed by performance bond? Yes No

8c. If “Yes” to either item 8a or 8b specify location(s) and reason(s) why: Yes No

8d. Did you look at the project site(s) on-the-ground? Yes No

United States

Department of Agriculture

Forest Service

Job Corps

Acquisition Management

1617 Cole Blvd., Bldg 17, Lakewood, CO 80401

Previous edition is obsolete Page 2 of 2 FS-6300-27 (3/00)

9. Organization and work that will be available for this project.

a. (1) Minimum number of employees: _____ and a (2) Maximum number of employees: ______ ?

b. Are employees regularly on your payroll: Yes No

c. Specify equipment available for this contract:

d. Estimate rate of progress below (such as 2.0 acres/man/day):

(1) Minimum progress rate: ________________________________ and (2) maximum progress rate:

10. List below the experience of the principal individuals of your business:

INDIVIDUAL’S NAME

PRESENT

POSITION

YEARS

OF EXP.

MAGNITUDE AND TYPE OF WORK

11. List all the equipment (including vehicles) you plan to use on this contract. Provide a detailed description of the Equipment including your maintenance plan.

12. Contractor Inspection. Describe Contractor Self Inspection Procedures which you will use to insure quality for this contract.

13. Remarks. Specify Box Numbers (Attach sheets if extra space is needed to fully answer any above question):

CERTIFICATION

I certify that all of the statements made by me are complete and correct to the best of my knowledge and that any person’s name as references are authorized to furnish the Forest Service with any information needed to verify my capability to perform this project.

12a. CERTIFYING OFFICIAL’S NAME AND TITLE

b. SIGNATURE (Sign in ink) 13. DATE