36C78619Q0151-003.docx

ATTACHMENT D - -PAST PERFORMANCE QUESTIONAIRE

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 no more than three (3) contracts for evaluation limited to the last five (5) 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?___________________________________________________________

Were you the Prime contractor?______________ were you the Sub contractor? ___________

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 quality, timeliness & relevancy of work:

Complexity of Product/Service, if any: