36C78619Q0128-0001003.docx

ATTACHMENT I

PAST PERFORMANCE QUESTIONNAIRE

INSTRUCTIONS: Offerors must identify previous federal, state, and local government and private contracts that they have completed and that are similar to the contract being evaluated. List at least three (3), but no more than five (5) contracts for evaluation limited to the last three (3) years. (One contract reference per form, Form may be duplicated) NOTE: If you have performed any National Cemetery Administration contracts list them first.

Contractor (you) Information:

Name: _____________________________________________________________________ Address: ___________________________________________________________________ Telephone Number: ___________________________________________________________ E-mail: ______________________________________________________________________

Contract Information:

Name of company/agency you provided service for: ___________________________________ Contract Number: _____________________________________________________________ Type of Contract: _______________________________________________________________ Contract Dollar Value: ___________________________________________________________ Date of Award: _________________________________________________________________ Status: Completed, Yes____ No____ If not completed, projected completion date____________ If not completed, why?___________________________________________________________

Point of Contact Information for the company/agency you serviced:

Name of the Contract Person & their position: ________________________________________ Address: ______________________________________________________________________ Telephone Number: _____________________________________________________________ E-mail: ________________________________________________________________________

Description of Supply/Service(s) provided, location & relevancy of work:

Complexity of Product/Service, if any:

Percentage of Work completed by your company/by subcontractor:

Provide information on problems encountered during performance of this contract and your corrective actions, (if applicable):

(End of Section)