ATTACHMENT_B-Experience_Questionnaire_for_RFP_15-249-SOL-00039.docx

ATTACHMENT B

EXPERIENCE QUESTIONNAIRE

15-249-SOL-00039-Pediatric Dentist and or Endodontist Services

Use the following, or similar, form to submit your (Offeror’s) Qualifications Statement.

Tucson Area Office Indian Health Service

EXPERIENCE QUESTIONNAIRE

Instructions: See Box 8, Remarks, if extra space is needed to answer any item below. Mark “X” in appropriate boxes.

1. Contractor Name, Address, and Telephone Number

2. Submit to: Katheryn Camacho, Contract Specialist Email: katheryn.camacho@ihs.gov Fax: 520/295-2626

3. Business [ ] Company [ ] Co-partnership [ ] Corporation [ ] Individual [ ] Non-profit Organization

4. How many years do you or your firm have in the line of work contemplated by this solicitation?

5. How many years experience have you or your business had as a (a) prime contractor ____ and/or (b) sub-contractor ____?

6. List below the projects your business has completed within the last TWO (2) years:

7a. Have you ever failed to complete any work awarded to you? [ ] Yes [ ] No 7b. Has work ever been completed by a performance bond? [ ] Yes [ ] No 7c. If “Yes” to either item 7a. or 7b., specify location(s) and reason(s) why:

8. Remarks -- Specify Box Numbers (Attach sheets if extra space is needed to fully answer any above question(s).):

NOTE: PLEASE PROVIDE ANY ADDITIONAL INFORMATION THAT WILL HELP EVALUATE YOUR ABILITY TO SUCCESSFULLY COMPLETE THIS PROJECT.

CERTIFICATION

I certify that all of the statements made by me are complete and correct to the best of my knowledge, and that any persons named as references are authorized to furnish the Indian Health Service with any information needed to verify my capability to perform this project.

9a. CERTIFYING OFFICIAL’S NAME AND TITLE