36C25718Q9862-0005001.docx

ATTACHMENT 1 – PAST EXPERIENCE REFERENCES

Name of company submitting this form: ___________________________________________

Complete the following past experience information for your top five Department of Veterans Affairs (VA) Facilities. Past experience information submitted should be for five VA Medical Center Contracts performed within the past three years. If your company has not provided Solid Waste Pickup & Disposal Services to five VA’s, include information for five non-VA Facilities. First, provide information for any VA’s, then, information for services to other federal government facilities (Department of Defense, Public Health, Bureau of Prisons, etc.), and then, commercial facilities. These should be contracts directly provided to the facility listed and not a subcontract.

1. Facility Name:

Facility is: (put “X “ in blank in front of correct response) ____ VA Facility ____Other non-VA Federal Facility ____ State Facility ____Commercial Facility Point of Contact:

Phone Number:

Services Provided:

Email Address: _______________________________________________________ Contract Number: ______________________Date Service Provided: ______________

2. Facility Name:

Facility is: (put “X “ in blank in front of correct response) ____ VA Facility ____Other non-VA Federal Facility ____ State Facility ____Commercial Facility Point of Contact:

Phone Number:

Services Provided:

Email Address: _______________________________________________________ Contract Number: ______________________Date Service Provided: ______________

3. Facility Name:

Facility is: (put “X “ in blank in front of correct response) ____ VA Facility ____Other non-VA Federal Facility ____ State Facility ____Commercial Facility Point of Contact:

Phone Number:

Services Provided:

Email Address: _______________________________________________________ Contract Number: ______________________Date Service Provided: ______________

4. Facility Name:

Facility is: (put “X “ in blank in front of correct response) ____ VA Facility ____Other non-VA Federal Facility ____ State Facility ____Commercial Facility Point of Contact:

Phone Number:

Services Provided:

Email Address: _______________________________________________________ Contract Number: ______________________Date Service Provided: ______________

5. Facility Name:

Facility is: (put “X “ in blank in front of correct response) ____ VA Facility ____Other non-VA Federal Facility ____ State Facility ____Commercial Facility Point of Contact:

Phone Number:

Services Provided:

Email Address: _______________________________________________________ Contract Number: ______________________Date Service Provided: ______________