Attach_4_-_Past_Performance_Survey.docx

PAST AND PRESENT PERFORMANCE SURVEY

Your Company Name: Street Address: City, State and ZIP Code:

1. GENERAL BUSINESS INFORMATION

Date Firm Organized/Established:

2. FINANCIAL INFORMATION

a. Name of your bank: Mailing Address: City, State (including ZIP Code): Point of Contact: Telephone No.: ( )

b. Estimating is performed by a separate department [ ], accounting department [ ], contract department [ ]; or OTHER. If “OTHER”, explain:

3. CONTRACTS/SUBCONTRACTS COMPLETED OR IN PROGRESS

Complete and submit the information requested on page 2-4 below on prime contracts or subcontracts completed or in progress. Some Government contracts are preferred; but, if you have not performed Government contracts, indicate any other contracts completed or in progress.

Attachment 4page 3 of 5

a. First Contract:

Contracting Agency or Company: Point of Contact: Telephone Number: Contract Number: Contract/Subcontract Amount: $ Project Title and Location:

General Scope of Design Build Project:

Your Role (General Contractor [ ], Joint Venture [ ], Designer [ ], or Subcontractor [ ]) and the work your firm performed:

Describe any Work You Subcontracted to Others:

Total Amount of Subcontract(s): $ Period of Performance: days Scheduled Completion Date:

Actual Completion Date: Percentage of Work Completed: % Were You Terminated? Were You Assessed Liquidated Damages?

(If the answer to either Question is “Yes”, Explain:

Did you use a Quality Control Plan? Did you use a Safety Plan?

Quality Control or Safety Problems encountered (if any):

How were the problems resolved?

b. Second Contract:

Contracting Agency or Company: Point of Contact: Telephone Number: Contract Number: Contract/Subcontract Amount: $

General Scope of Construction Project:

Your Role (General Contractor [ ], Joint Venture [ ], Designer [ ], or Subcontractor [ ]) and the

Describe any Work You Subcontracted to Others:

Total Amount of Subcontract(s): $ Period of Performance: days Scheduled Completion Date:

Actual Completion Date: Percentage of Work Completed: % Were You Terminated? Were You Assessed Liquidated Damages?

(If the answer to either Question is “Yes”, Explain:

Did you use a Quality Control Plan? Did you use a Safety Plan? Quality Control or Safety Problems encountered (if any):

How were the problems resolved?

c. Third Contract:

Contracting Agency or Company: Point of Contact: Telephone Number: Contract Number: Contract/Subcontract Amount: $

General Scope of Construction Project:

Your Role (General Contractor [ ], Joint Venture [ ], Designer [ ], or Subcontractor [ ]) and the

Describe any Work You Subcontracted to Others:

Total Amount of Subcontract(s): $ Period of Performance: days Scheduled Completion Date:

Actual Completion Date: Percentage of Work Completed: % Were You Terminated? Were You Assessed Liquidated Damages?

(If the answer to either Question is “Yes”, Explain:

Did you use a Quality Control Plan? Did you use a Safety Plan? Quality Control or Safety Problems encountered (if any):

4. Certification of Past and Present Performance Information:

Type or Print Information

Name of Survey Preparer

Title

Signature

Date