Attachment 4 Exp Questionnaire and Past Performance Info.docx

USDA Forest Service

EXPERIENCE QUESTIONNAIRE

Instructions: Complete this form and check the applicable boxes. If extra space is needed to answer any item below, the offeror may use separate document.

1. Contractor Name, Address, and Telephone Number Name & Address: _______________________________

Phone: ___________________________________

Email: ___________________________________

UEI SAM #: _______________________________

2. Submitted with quote to joanne.meiers@usda.gov

3. Business

· Company 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’ experience in contracting have you or your business had for similar work as the following:

(a) Prime contractor ________ and/or (b) Sub-contractor ______?

6. List below the similar/relevant projects your business has completed within the last three years; include at least 3 projects:

Contract Amount

Completed Name, Address, and Phone No. of Owner/Person to Contract for Project Information

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

Contract Amount Dollar Amount of Award

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:

If Yes, comments (8c.):

9. Past Performance

The following definitions for Past Performance are what offerors are being evaluated:

Past Performance definitions:

Offeror may use a separate sheet of paper if necessary.

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

10.a. List below the Equipment for use on this project:

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

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.

12a. Contractor Certifying Official’s Name and Title:

12b. Signature (Sign in Ink or E-Signature):

12c. Date

Attachment 4: Experience Questionnaire and Past Performance Information Forms

PAST PERFORMANCE INFORMATION

NOTE: Offeror may submit this information using the template below or a separate form/format, but offeror must respond with all information. List all contracts or subcontracts you have been involved with in the past three years (List three minimum). You may also include projects over three years which are directly applicable to the type of work required by this solicitation/requirement. If you already submitted this information on the form above, disregard.

Name of Offeror: _____________________________________________ UEI SAM #:______________________________________________

Contracting Activity (Forest Service, etc.)

Contract Number

Contract Type (service, construction, fixed price, hourly, etc.)

Contract Amount

Completion Date

Type of Work (Grading, Road Maint., Blading, etc.)

Contracting Officer (CO)

NAME:

PHONE:

EMAIL:

NAME:

PHONE:

EMAIL:

NAME:

PHONE:

EMAIL:

Technical / Contracting Officer Representative (COR)

NAME:

PHONE:

EMAIL:

NAME:

PHONE:

EMAIL:

NAME:

PHONE:

Major Sub-contractors

BUSINESS NAME:

PHONE:

EMAIL:

BUSINESS NAME:

PHONE:

EMAIL:

BUSINESS NAME:

PHONE:

NOTE: Please use blank copies of this page if you need additional space to include all appropriate past performance jobs.