ATTCH_I_past_performance_questionaire.docx

SPED Speech Therapy Services Page 2 of 2 Attachment 1 Present and Past Performance Questionnaire

PRESENT AND PAST PERFORMANCE QUESTIONNAIRE

A. PLEASE PROVIDE THREE (3) PAST AND/OR PRESENT PERFORMANCE REFERENCES FOR THE MOST RECENT, RELEVANT CONTRACTS. DO NOT INCLUDE CLASSIFIED PROGRAMS. PLEASE RETURN THIS PACKAGE WITH YOUR BID/PROPOSAL/QUOTATION.

OFFEROR’S/BIDDER’S NAME (Company/Division): _________________________________________________

JOB 1

1. CONTRACT NUMBER: ________________________________ 2. TYPE: ____________________________

3. BUYING OFFICE:

a. Address: _________________________________________________________________________________

b. Phone: __________________________________________________________________________________

c. Contracting Officer/Point of Contact: __________________________________________________________

4. BRIEF DESCRIPTION OF EFFORT: ____________________________________________________________

5. CONTRACT $ VALUE: a. Original: _________________________________________________________

b. Value at Completion: _______________________________________________

c. Reason for any Change: _____________________________________________

6. PERFORMANCE PERIOD: a. Date Completed/To Be Completed: ____________________________________

b. Reason for Any Change: ____________________________________________

7. USE THIS SPACE TO ADDRESS ANY TECHNICAL (OR OTHER) AREA OF CONCERN CONSIDERED

UNIQUE: _____________________________________________________________________________________

JOB 2

3. BUYING OFFICE:

a. Address: _________________________________________________________________________________

b. Phone: ___________________________________________________________________________________

c. Contracting Officer/Point of Contact: ___________________________________________________________

JOB 2 (cont)

4. BRIEF DESCRIPTION OF EFFORT: ____________________________________________________________

5. CONTRACT $ VALUE: a. Original: _________________________________________________________

b. Value at Completion: _______________________________________________

c. Reason for any Change: _____________________________________________

6. PERFORMANCE PERIOD: a. Date Completed/To Be Completed: ____________________________________

b. Reason for Any Change: ____________________________________________

7. USE THIS SPACE TO ADDRESS ANY TECHNICAL (OR OTHER) AREA OF CONCERN CONSIDERED

UNIQUE: _____________________________________________________________________________________

JOB 3

3. BUYING OFFICE:

a. Address: _________________________________________________________________________________

b. Phone: ___________________________________________________________________________________

c. Contracting Officer/Point of Contact: ___________________________________________________________

4. BRIEF DESCRIPTION OF EFFORT: ____________________________________________________________

5. CONTRACT $ VALUE: a. Original: _________________________________________________________

b. Value at Completion: _______________________________________________

c. Reason for any Change: _____________________________________________

6. PERFORMANCE PERIOD: a. Date Completed/To Be Completed: ____________________________________

b. Reason for Any Change: ____________________________________________

7. USE THIS SPACE TO ADDRESS ANY TECHNICAL (OR OTHER) AREA OF CONCERN CONSIDERED

UNIQUE: _____________________________________________________________________________________