Attachment_3_,_Prime_Contractor_Past_Performance_Survey.doc

ATTACHMENT 3 Solicitation # 140F0219R0019 page 1 of 3

PRIME CONTRACTOR PAST AND PRESENT PERFORMANCE SURVEY

Your Company Name:

Street Address:

City, State and ZIP Code:

1. GENERAL BUSINESS INFORMATION

Date Firm Organized/Established:

Company President:

Vice President:

Dun & Bradstreet Number:

Is company a; Partnership [ ] Separate entity [ ] Division [ ] N/A [ ]

2. 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. Government contracts are preferred; but, if you have not performed Government contracts, indicate any other contracts completed or in progress.

a. First Contract:

Contracting Agency or Company:

Point of Contact:

Telephone Number:

Contract Number:

Contract/Subcontract Amount: $

Project Title and Location:

General Scope of Project:

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

Period of Performance: days Scheduled Completion Date:

Actual Completion Date:

Percentage of Work Completed:

b. Second Contract:

Contracting Agency or Company:

Point of Contact:

Telephone Number:

Contract Number:

Contract/Subcontract Amount: $

Project Title and Location:

General Scope of Project:

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

Period of Performance: days Scheduled Completion Date:

Actual Completion Date:

Percentage of Work Completed:

3. Certification of Past and Present Performance Information:

Type or Print Information

Name of Survey Preparer _______________________________Phone:_________________

E-Mail;___________________________

Title__________________________________________

Signature______________________________________

Date__________________________________________