36C24421R0028 0003.docx

Department of Veterans Affairs

Network Contracting Office 4 Wilkes-Barre VAMC 1111 East End Blvd 11 1111 East End Blvd Wilkes-Barre PA 18711

5. PROJECT NUMBER (if applicable)

CODE

7. ADMINISTERED BY

2. AMENDMENT/MODIFICATION NUMBER

CODE

6. ISSUED BY

8. NAME AND ADDRESS OF CONTRACTOR

4. REQUISITION/PURCHASE REQ. NUMBER

3. EFFECTIVE DATE

9A. AMENDMENT OF SOLICITATION NUMBER

9B. DATED

PAGE OF PAGES

10A. MODIFICATION OF CONTRACT/ORDER NUMBER

10B. DATED

BPA NO.

1. CONTRACT ID CODE

FACILITY CODE

CODE

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods:

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers

E. IMPORTANT:

is extended,

(a) By completing Items 8 and 15, and returning __________ copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY is not extended.

12. ACCOUNTING AND APPROPRIATION DATA

(REV. 11/2016)

is required to sign this document and return ___________ copies to the issuing office.

is not, A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER NO. IN ITEM 10A.

15C. DATE SIGNED

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or electronic communication, provided each letter or electronic communication makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER

Contractor

16C. DATE SIGNED

14. DESCRIPTION OF AMENDMENT/MODIFICATION

16B. UNITED STATES OF AMERICA

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15A. NAME AND TITLE OF SIGNER

16A. NAME AND TITLE OF CONTRACTING OFFICER

15B. CONTRACTOR/OFFEROR

STANDARD FORM 30

PREVIOUS EDITION NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.243 (Type or print) (Type or print) (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

(Number, street, county, State and ZIP Code) (If other than Item 6) (Specify type of modification and authority) (such as changes in paying office, appropriation date, etc.)

(If required)

(SEE ITEM 11)

(SEE ITEM 13)

(X)

CHECK

ONE

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS,

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

(Signature of person authorized to sign) (Signature of Contracting Officer) none 00244

00244

To all Offerors/Bidders

36C24421R0028 08-03-2021

X x

This amendment changes the no later than date for PPQ submission FROM 4:00pm local time, August 12, 2021 TO: 4:00pm local time, August 19,2021. See atatched revised PPQ.

MICHAEL F. WHITE

Contract Officer michael.white9@va.gov

Past Performance Questionnaire for: 36C24421R0028, Wilkes-Barre MATOC

INSTRUCTIONS TO OFFEROR

Complete the CONTRACTOR INFORMATION section, below (type answers into light blue shaded boxes). Save the document. Send an electronic or hard copy print of the form to each of your reference contacts, asking them to please complete the form and submit it according to the instructions, below.

Company Name

Street Address

Point of Contact (POC)

City

POC Phone Number

State

Reference Project Title

Zip Code

Contract Period of Performance (start to finish):

Email

Contract Number

Contract Dollar Value

Description of Work

INSTRUCTIONS TO REFERENCE CONTACT

The contractor named above is submitting a proposal for a United States Department of Veterans Affairs contract, and has sent this form to you as a past performance reference contact. Please complete the following pages in full (all areas shaded in light yellow, below). Once completed, please send the form to the Contracting Officer via email directly to:

Department of Veterans Affairs NCO 4 Contracting Office ATTN: 36C24419R0028, Wilkes-Barre MATOC

Email Address: michael.white9@va.gov and scot.plank@va.gov

Please return the completed form ASAP, but no later than 4:00 pm local time, DATE August 19, 2021

If you have any questions, please contact the Contract Officer: Mike White via email michael.white9@va.gov

RESPONDENT INFORMATION [completed by Reference Contact]

Company Name

Street Address

POC Name

City

Phone Number

State

Email

Zip Code

PERFORMANCE INFORMATION: Choose the number on the scale of 0 (Neutral) to 5 (Exceptional) that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE AN EXPLANATION FOR THE OVERALL RATING in the Remarks section, below.

QUALITY – MANAGEMENT & WORKMANSHIP

TIMELINESS AND ADHERENCE TO SCHEDULE

REMARKS:

BUSINESS PRACTICES/CUSTOMER RELATIONSHIP AND ABILITY TO PERFORM

COMPLIANCE & SAFETY

INFECTION CONTROL

OVERALL CUSTOMER SATISFACTION

REMARKS (Please use as much space as is needed – the box will expand as you type).

I hereby certify that the information that I have reported above is accurate to the best of my knowledge.

Printed Name

E-mail address

Business Title

Signature

Date

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