Attachment D.4 - Past Experience Reference Questionnaire Amendment A00001.docx

FOR OFFICIAL USE ONLY

Source Selection Sensitive Information—See FAR 2.101 & 3.104 Attachment D.5

PAST EXPERIENCE REFERENCE QUESTIONNAIRE (PERQ)

INSTRUCTIONS TO CONTRACTOR

Complete the CONTRACTOR INFORMATION section, below (type answers into light blue shaded boxes). Save the document. Send an electronic or hard copy print of the form to each of your reference contacts, asking them to please complete the form and submit it according to the instructions.

INSTRUCTIONS TO REFERENCE CONTACT

The contractor named below is submitting an offer for a United States Department of Veterans Affairs contract requirement and has sent this form to you for a past experience contract reference. Please complete this form in full (all areas shaded in light yellow). Once completed, please send the form to the Contracting Officer via email: Laura.Nabity@va.gov.

Department of Veterans Affairs PCAC ATTN: Laura Nabity, REF: RFQ 36C77623Q0063 Email Address: Laura.Nabity@va.gov

Please return the completed form no later than the date and time set for receipt of Quotes/Proposals. If you have any questions, please contact Laura Nabity via email. Thank you for your assistance in this matter.

GENERAL INFORMATION [completed by Contractor/Offeror]

Contractor Company Name

Street Address

Contractor Point of Contact Name

City

Point of Contact Phone Number

State

Reference Project / Contract Title

Zip Code

Contract Period of Performance (start to finish):

Email

Contract Number

Contract Dollar Value

Detailed Description of Work

RESPONDENT INFORMATION [completed by Reference Contact]

Company Name

Street Address

POC Name

City

Phone Number

State

Fax Number

Zip Code

Email

PERFORMANCE INFORMATION – Table 1: Choose the number on the scale of 1 to 4 that most accurately describes the contractor’s performance.

PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY NEGATIVE RATING(S) in the Remarks section below (text box will expand to if necessary).

PERFORMANCE INFORMATION – Table 2: Please answer the following questions regarding personnel.

Please provide any comments, narratives, or explanations on personnel below in the Remarks section below (text box will expand if necessary).

8.

Was the contractor ever issued a letter of concern, cure or show cause notice under the referenced contract? If yes, explain outcome in “remarks.”

REMARKS (Please use as much space as is needed – the box will expand as you type).