Attch6_RelevantExperienceSurvey_4pp.docx
DOCX document 24 KB Posted
- Attached to
- NE-RAINWATER BSN WMD HQ GEOTHERMAL HVAC
- Solicitation number
- 140FGA26Q0065
About this file
This is a Relevant Experience Survey template used to document a contractor's past or present contract performance history as part of a proposal submission.
The survey collects general business information including company name, address, establishment date, leadership, and SAM.gov registration details. Contractors must complete detailed sections for up to three past or present contracts or subcontracts, whether government or commercial. For each contract entry, the form requires the contracting agency or company name, point of contact, telephone number, contract number, contract amount, project title and location, scope of work, the contractor's role (prime, joint venture, or subcontractor), subcontract details, period of performance, scheduled and actual completion dates, and percentage of work completed. Additional required information includes termination status, quality control plan implementation, safety plan implementation, and descriptions of any quality control or safety problems encountered and their resolutions. The survey concludes with certification space for the survey preparer's name, phone number, email, title, signature, and date. This template is designed for use in responding to the U.S. Fish and Wildlife Service solicitation 140FGA26Q0065 for a geothermal HVAC system replacement and commissioning project at the Rainwater Basin Wetland Management District office in Nebraska, which is set aside for small businesses with contract values anticipated to exceed $35,000.
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PAST OR PRESENT RELEVANT EXPERIENCE
Your Company Name:
Street Address:
City, State and ZIP Code:
1. GENERAL BUSINESS INFORMATION
Date Firm Organized/Established:
| Company President: | Vice President: | |
| SAM.gov Unique Entity ID: | ___________________ |
Is company a ; Partnership [ ] Separate entity [ ] Division [ ] N/A [ ]
2. CONTRACTS/SUBCONTRACTS COMPLETED OR IN PROGRESS
Complete and submit the information requested 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:
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?
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: $ | _____ |
Project Title and Location:
General Scope of Project: ____________
Your Role (Prime [ ], Joint Venture [ ], or Subcontractor [ ]) and the work your firm performed:
Describe any Work You Subcontracted to Others:
Total Amount of Subcontract(s): $
Scheduled Completion Date:
Actual Completion Date: Percentage of Work Completed: % Were You Terminated?
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: $ | _____ |
Project Title and Location:
General Scope of Project: ____________
Your Role (Prime [ ], Joint Venture [ ], or Subcontractor [ ]) and the work your firm performed:
Describe any Work You Subcontracted to Others:
Total Amount of Subcontract(s): $
Scheduled Completion Date:
Actual Completion Date: Percentage of Work Completed: % Were You Terminated?
Quality Control or Safety Problems encountered (if any):
How were the problems resolved? _____
Type or Print Information Name of Survey Preparer
Phone:_ E-Mail;_ Title Signature Date )4. Certification of Past Performance Information:
File details come from the government source that posted it. Updated .