3_Past_Performance_Survey.pdf

ATTACHMENT 3 page 1 of 5

PAST OR 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.

ATTACHMENT 3 page 2 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 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?

ATTACHMENT 3 page 3 of 5

b. Second Contract:

Point of Contact: Telephone Number:

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

Scheduled Completion Date:

Actual Completion Date: Percentage of Work Completed: %

ATTACHMENT 3 page 4 of 5

c. Third Contract:

Point of Contact: Telephone Number:

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

Scheduled Completion Date:

Actual Completion Date: Percentage of Work Completed: %

ATTACHMENT 3 page 5 of 5

4. Certification of Past Performance Information:

Type or Print Information

Name of Survey Preparer _______________________________Phone:_________________

E-Mail;___________________________

Title__________________________________________

Signature______________________________________

Date__________________________________________