140F0418Q0062_Past_Performance_Questionnaire.rtf

Past Performance Questionnaire

The following information must be completed in its entirety. Ensure that the telephone and facsimile numbers are correct as failure to complete this information will only delay award.

Date: ______________________________

Telephone #: __________________________

Facsimile #: __________________________

Email Address: _______________________

DUNS#: ___________________________

Contractor Information Name & Address

How long in present business? ___________________________

Type of Organization: [ ] Individual [ ] Individual doing business as a Firm [ ] Partnership [ ] Joint Venture [ ] Corporation, Incorporated under the laws of the State of _________ [ ] Non~Profit Organization

Individuals and their telephone numbers authorized to sign bids, offers, and contracts in your name:

1. ____________________________________________________________________________________

2. ____________________________________________________________________________________

Work Performance

Current Projects similar to this project. (Preferably Government, Federal, State, County):

1. Name of Project:_______________________________________________________________________

Contract/Project Number: ________________________________________________________

Location:____________________________________________________________________________

Point of Contact:____________________________________ Telephone #:____________________

Dollar amount of Project:_____________________________ Facsimile #:____________________

Completion Date: __________________________________

2. Name of Project:_______________________________________________________________________

Contract/Project Number: ________________________________________________________

Location:____________________________________________________________________________

Point of Contact:____________________________________ Telephone #:____________________

Dollar amount of Project:_____________________________ Facsimile #:____________________

3. Name of Project:_______________________________________________________________________

Location:____________________________________________________________________________

Point of Contact:____________________________________ Telephone #:____________________

Dollar amount of Project:_____________________________ Facsimile #:____________________

Past Projects similar to this project and completed during the past three years. (Preferably Government, Federal, State, County):

1. Name of Project:_______________________________________________________________________

Contract/Project Number: ________________________________________________________

Location:____________________________________________________________________________

Point of Contact:____________________________________ Telephone #:____________________

Dollar amount of Project:_____________________________ Facsimile #:____________________

2. Name of Project:_______________________________________________________________________

Location:____________________________________________________________________________

Point of Contact:____________________________________ Telephone #:____________________

Dollar amount of Project:_____________________________ Facsimile #:____________________

3. Name of Project:_______________________________________________________________________

Location:____________________________________________________________________________

Point of Contact:____________________________________ Telephone #:____________________

Dollar amount of Project:_____________________________ Facsimile #:____________________