36C78619R0067-006.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.

Offerors must list at least three (3) within the past three years for evaluation. (One contract reference per form, Form may be duplicated)

NOTE: If you have performed any National Cemetery Administration contracts list them first.

Contract Number: ___________________________________________________________

Contractor (Name, Address, Zip Code & Telephone# & email address):

Type of Contract: ______________________________________________________

Contract Dollar Value: __________________________________________________

Date of Award: ________________________________________________________

Status: Completed, Yes____ No ____ If not completed, Projected completion date___________

Description of supply/services provided, location & relevancy of work, Complexity of Product/Service:

Percentage of Work completed by your company, Type/Extent of Subcontractor and their % of work:

Information on the company/agency you serviced:

Name of Company you provided services for:

Address:______________________________________________________________________

Contact Person’s Name & Title/position:

Telephone:_____________________________________________________________________

Email:________________________________________________________________________