36C26018R0178-003.docx

APPENDIX A

GENERAL CONTRACTOR REFERENCE FORM

Offeror:

Solicitation No:

Contract No: Project No:

Project Title:

Location:

Owners Name and Title:

Phone: Email:

Gov’t Contracting Officer if applicable:

Phone: Email:

Identify if considered Prime Contractor or Subcontractor:

Project Delivery Method (Design-Build, Design-Bid-Build, Other (specify))

Type of Contract (FFP, FFP-EPA, Cost-Plus, etc. (specify))

OSHA Inspection/NOVs (If Applicable):

General Scope of Work:

List All Major Subcontractors w/POC and Phone No:

(continued)

Offeror:

Solicitation No:

Contract No: Project No:

Implementation of Infection Control Requirements:

Describe sustainability requirements (LEED, Green Globes, etc.), the approach and the level attained:

Describe any terminations (partial or complete), the reason (convenience or default) and the surrounding circumstances:

Complete one form for each of the sample projects