36C24718R0541-033.pdf

ATTACHMENT 4

CONTRACTOR EXPERIENCE FORM

1. Project name and location (City, State, Country)

2. Project owners name and address: (Government Agency, commercial firm or other organization)

3. Project owners Point of Contract Information: (name, phone, email address)

4. Were you the Prime Contractor? YES NO Percentage of work that was self-performed? ____________%

5. Contract number of project 6. Date of contract

7. Date work began 8. Completion Dates:

Initial: ________________

Actual: _______________

9. Project Completion Percentage (%)

8. Contract Value at Time of Award 9. Final invoiced amount (or amount invoiced to date)

10. Description of Construction contract work - describe nature and scope of work. Detail how project demonstrates experience requirements Use continuation sheet for additional information, if necessary.

11. Current status of project (check one) ___ Work continuing, on schedule ___ Work continuing, behind schedule ___ Work completed, no further action pending ___ Work completed, routine administrative action pending ___ Work completed, claims negotiation pending/underway ___ Work completed, litigation pending/underway ___ Terminated for convenience ___ Terminated for default ___ Other (Explain, use additional sheets as necessary)