36C25621R0122 EXHIBIT C.docx
DOCX document 26 KB Posted
- Solicitation number
- 36C25621R0122
About this file
This document contains a consent form and reference list for subcontractors bidding on a federal contract opportunity to renovate a cardiac catheterization laboratory at the Overton Brooks VA Medical Center in Shreveport, Louisiana. The opportunity is a 100% set-aside for Service-Disabled Veteran-Owned Small Businesses with a construction cost range between $2 million and $5 million. Interested offerors are asked to read the full solicitation when it is posted to the SAM website on or around August 2, 2021, with proposals due September 1, 2021. Subcontractors are requested to complete the consent form to allow their past performance information to be shared with any prime contractor, and provide a reference list including contract details and points of contact. The work is expected to take 808 calendar days to complete once a notice to proceed is issued.
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Text version
FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project 667-15-104 Renovate Cath Lab, 6E 36C25621R0122
EXHIBIT C – SUBCONTRACTOR INFORMATION AND CONSENT FORM
Subcontractor and/or Teaming Partner Consent for the Release of Past Performance Information to the Prime Contractor and Reference Information
Past performance information concerning subcontractors and teaming partners cannot be disclosed to a private party without the subcontractor’s or teaming partner’s consent. Because a prime contractor is a private party, the Government will need that consent before disclosing subcontractor/teaming partner past and present performance information to the prime during exchanges. In an effort to assist the Government in assessing your past performance relevancy we request that the following consent form be completed by the major subcontractors/teaming partners identified in your proposal. The completed consent forms should be submitted to the offering contractor for submission with past performance volume.
Name of Firm: _________________________________
| (That is currently planning on participating as a subcontractor and or a teaming partner with) |
| Telephone:______________ |
Address:________________
City/State/Zip Code:_______
DUNS/Cage Code:__________________
Name of Prime:__________________________________
| (PRIME CONTRACTOR OR NAME OF ENTITY PROVIDING PROPOSAL in responding to the Request for Proposal No. 36C25621R0122 for Project 667-15-104 Renovate Cath Lab, 6E) |
| Telephone:__________________ |
Address:____________________
City/State/Zip Code:___________
DUNS/Cage Code:____________
We understand that the Government is placing increased emphasis on past performance in order to obtain best value in source selections. In order to facilitate the performance confidence assessment process, we are signing this consent form to allow you to discuss our past and present performance information with the prime contractor during the source selection process.
| Signature:___________________________________ |
| ___________________________ |
Title of Individual with authority to sign for and Legally bind the company
Reference List (required):
Contract No. And Title:
Describe role (Prime/Sub) and work Performed
Reference POC Name
Email address & Phone #
Contract No. And Title:
Describe role (Prime/Sub) and work Performed
Reference POC Name
Email address & Phone #
Contract No. And Title:
Describe role (Prime/Sub) and work Performed
Reference POC Name
Email address & Phone #
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