36C78619Q0366-004.pdf

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 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? ________ were you the Sub? _______

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:

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