A10. J15_Experience & PastPerf Questionnaire.docx

United States Department of Agriculture

Forest Service

Rocky Mountain Acquisition Management

2150 Centre Ave., Bldg. E Fort Collins, CO 80526

Experience and Past Performance Questionnaire

Solicitation No. 12970224R0036

1. Contractor Name, Address and Telephone No.

Overwrite Here

2. Submitted To.

USDA Forest Service Attn: Klenise Wallace, Contracting Officer Email: klenise.wallace@usda.gov

3. Business ☐ Individual ☐ Company ☐ Co-partnership ☐ Corporation ☐ Non-profit Organization

4. How many years of experience in contracting have you or your business had as a:

(a) Prime contractor?

(b) Sub-contractor?

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

(a) You?

(b) Firm?

☐ Not Applicable. I do not have experience in the line of work contemplated by this solicitation.

☐ Not Applicable. This is the firms first opportunity in this line of work.

☐ Other – Explain.

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 6c. If “Yes” to either item 6a or 6b specify location(s) and reason(s) why: ☐Yes ☐ No

6d. If “Yes” to item 6c, did you look at the project site(s) on-the-ground? ☐ Yes ☐ No

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

7a. (1) Minimum number of employees:

(2) Maximum number of employees:

7b. Are employees regularly on your payroll: ☐ Yes ☐ No 7c. Do you anticipate using subcontractors? ☐ Yes ☐ No NOTE: If the answer is “Yes” to 7c, you must complete and submit the SF 1413 for each subcontractor performing work on the project site.

8. List below the experience of the principal individuals of your business. Include a resume not to exceed 2 pages for each person listed.

INDIVIDUAL’S NAME

(8a)

PRESENT

POSITION

(8b)

YEARS

OF EXP.

(8c) MAGNITUDE AND TYPE OF WORK (NTE 3 Sentences) (8d)

9(a). PROJECT 1

☐ Prime ☐ Sub-contractor

☐ Complete ☐ Still Ongoing ☐ Terminated for -- ☐ Convenience / ☐ Default

P1h. Provide the type of project and brief description addressing the solicitation information requested for the Experience and Past Performance factors. Do not exceed the space provided. Only the project discussed above shall be provided herein.

Type Here

P1i. Provide the type of project and brief description addressing the solicitation information requested for the Past Performance factor. Do not exceed the space provided. Only the project discussed above shall be provided herein.

Type Here

9(b). PROJECT 2

☐ Prime ☐ Sub-contractor

☐ Complete ☐ Still Ongoing ☐ Terminated for -- ☐ Convenience / ☐ Default

P2h. Provide the type of project and brief description addressing the solicitation information requested for the Experience and Past Performance factors. Do not exceed the space provided. Only the project discussed above shall be provided herein.

Type Here

P2i. Provide the type of project and brief description addressing the solicitation information requested for the Past Performance factor. Do not exceed the space provided. Only the project discussed above shall be provided herein.

9(c). PROJECT 3

☐ Prime ☐ Sub-contractor

☐ Complete ☐ Still Ongoing ☐ Terminated for -- ☐ Convenience / ☐ Default

P3h. Provide the type of project and brief description addressing the solicitation information requested for the Experience and Past Performance factors. Do not exceed the space provided. Only the project discussed above shall be provided herein.

Type Here

P3i. Provide the type of project and brief description addressing the solicitation information requested for the Past Performance factor. Do not exceed the space provided. Only the project discussed above shall be provided herein.

9(d). PROJECT 4

☐ Prime ☐ Sub-contractor

☐ Complete ☐ Still Ongoing ☐ Terminated for -- ☐ Convenience / ☐ Default

P4h. Provide the type of project and brief description addressing the solicitation information requested for the Experience and Past Performance factors. Do not exceed the space provided. Only the project discussed above shall be provided herein.

Type Here

P4i. Provide the type of project and brief description addressing the solicitation information requested for the Past Performance factor. Do not exceed the space provided. Only the project discussed above shall be provided herein.

9(e). PROJECT 5

☐ Prime ☐ Sub-contractor

☐ Complete ☐ Still Ongoing ☐ Terminated for -- ☐ Convenience / ☐ Default

P5h. Provide the type of project and brief description addressing the solicitation information requested for the Experience factor. Do not exceed the space provided. Only the project discussed above shall be provided herein.

Type Here

P5i. Provide the type of project and brief description addressing the solicitation information requested for the Past Performance factor. Do not exceed the space provided. Only the project discussed above shall be provided herein.

10. Equipment. In the space provided, list all the equipment you own or have available through direct ownership or a rental agreement to be used on this contract/agreement, to include maintenance and cleaning plans.

Equipment Name/Type, Make & Model (10a) Year (10b) Owned (10c) Rented (10d) Brief Description of Maintenance &Cleaning Plans (10e)

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.

CERTIFYING OFFICIAL’S NAME AND TITLE

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