36C24719R0039-003.docx

Attachment 1 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

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. Describe any difficulties and/or obstacles encountered during performance; steps taken toward resolution

12. Describe unforeseen conditions and how each were resolved

13. 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)