36C25622R0088 EXHIBIT C.docx

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Z2LZ--Project #629-18-115 Install Signs and Striping for Garages - Construction
Solicitation number
36C25622R0088
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This document contains a subcontractor information and consent form template for the solicitation numbered 36C25622R0088 to install signs and striping for garages at a Veterans Affairs medical center. Major subcontractors are requested to complete the form to consent to the release of their past performance information to the prime contractor. The form requires the subcontractor's name, address, DUNS/CAGE code, and signature of an authorized individual. It also requests a reference list including contract numbers and titles, the subcontractor's role, work performed, and points of contact with email and phone numbers for three past contracts. The related federal contract opportunity is for Project 629-18-115 to install signs and striping for garages through a construction solicitation issued by the Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16.

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FOR OFFICIAL USE ONLY

Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project 629-18-115 Install Signs and Striping for Garages 36C25622R0088

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. 36C25622R0088 for Project 629-18-115 Install Signs and Striping for Garages)
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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