36C25622R0067 EXHIBIT C R1.docx
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- Solicitation number
- 667-22-4-1404-0033
About this file
This document contains a subcontractor information and consent form for solicitation number 667-22-4-1404-0033 to upgrade the water distribution system at the main hospital in Shreveport, Louisiana. The subcontractor consent form requests contact information and allows the disclosure of past performance information to the prime contractor. It also requires a list of three past contract references that include the contract number, role, work performed, and point of contact information. The related federal contract opportunity is a 100% Service-Disabled Veteran-Owned Small Business set-aside to upgrade the water distribution system at the main hospital in Shreveport, Louisiana being conducted by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16. Responses are required in accordance with the solicitation package.
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FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 667-18-119 Repair Water Distribution System – Main Hospital 36C25622R0067
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. 36C25622R0067 for Project No. 667-18-119 Repair Water Distribution System – Main Hospital |
| 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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