36C25622R0065 EXHIBIT C R1.docx
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- Attached to
- Z1DA--667-18-121 Upgrade & Replace Surgery HVAC System & Roofing Federal contract opportunity
- Solicitation number
- 36C25622R0065
About this file
This document contains a subcontractor consent form and reference list for the solicitation notice Project 667-18-121 Upgrade Surgery HVAC & Roofing. The solicitation is seeking proposals to upgrade and replace the surgery HVAC system and roofing at the Overton Brooks VA Medical Center in Shreveport, Louisiana. Major subcontractors and teaming partners identified in proposals must complete the consent form to allow their past performance information to be discussed with the prime contractor during source selection. The consent form requires the subcontractor's name, address, DUNS and SAM identifiers, as well as the prime contractor's information. It also includes a reference list for the subcontractor to provide contract numbers, titles, roles, work performed, and points of contact for three past performance references.
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Text version
FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 667-18-121 Upgrade Surgery HVAC & Roofing 36C25622R0065
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/SAM Unique Identifier Codes:_________________
Name of Prime:__________________________________
| (PRIME CONTRACTOR OR NAME OF ENTITY PROVIDING PROPOSAL in responding to the Request for Proposal No. 36C25622R0065 for Project No. 667-18-121 Upgrade Surgery HVAC & Roofing |
| Telephone:________________ |
Address:__________________
City/State/Zip Code:___________
DUNS/Cage/SAM Unique Identifier Codes:____________
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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