A-10 Experience Questionnaire.pdf

USDA – Forest Service

EXPERIENCE QUESTIONNAIRE

INSTRUCTIONS: See Box 12, Remarks, if extra space is needed to answer any questions below Mark “X” in appropriate boxes.

1. CONTRACTOR NAME, ADDRESS, AND

TELEPHONE NO.

2. SUBMITTED TO (office Name and Address) USDA Forest Service, Region 5 Northern California Acquisition Service Area 2550 Riverside Drive Susanville CA 96130

3. BUSINESS

☐ Company ☐ Co-partnership ☐ Corporation ☐ Individual ☐ Non-profit Organization

4. How many years do you or your firm have in the line of work contemplated by this solicitation?

5. How many years of experience in contracting have you or your business had as a (a) prime contractor ____ and/or (b) sub-contractor ____?

6. List below the relevant projects your business has ongoing or completed within the last three years where we can confirm that your company has experience in similar work and the customer satisfaction of that work:

CONTRACT

NUMBER

DOLLAR AMT

OF AWARD

NAME, ADDRESS, AND TELEPHONE NO. OF

OWNER/PERSON TO CONTACT FOR PROJECT

INFORMATION

TYPE OF PROJECT

ONGOING

OR

DATE COMPLETED

7. List below all of your firm’s contractual commitments running concurrently with the work contemplated by this solicitation:

CONTRACT

NUMBER

DOLLAR AMT.

OF AWARD

NAME, ADDRESS, AND TELEPHONE NO. OF

BUSINESS/GOVERNMENT AGENCY INVOLVED

AWARDED

(Units)

PERCENT

COMPLETED

DATE CONTRACT

COMPLETED

8a. Have you ever failed to complete any work awarded to you? ☐ Yes ☐ No 8b. Has work ever been completed by performance bond? ☐ Yes ☐ No If “Yes” to either item 8a or 8b specify location(s) and reason(s) why:

8c. Did you look at the project site(s) on-the-ground? ☐ Yes ☐ No If “Yes”, how extensive was your site visit for this project? (e.g., ‘drove by some areas;’ ‘walked area.’) What did the site visit reveal about the comparative difficulty of the project—e.g., the problems that are likely to be encountered during performance?

9. Organization and work that will be available for this project.

a. Minimum number of employees: _____ and; Maximum number of employees: ______

b. Are employees regularly on your payroll? ☐ Yes ☐ No

c. List all the equipment you own or have available through a rental agreement to be used on this contract/agreement. Provide a detailed description of the Equipment including your maintenance and cleaning plans.

d. Estimate rate of progress below (if applicable) Minimum progress rate: _________________________________ and; maximum progress rate: _________________________________

e. Subcontractors (if any) Name Experience % of work to be completed by sub

f. Describe your proposed work plan indicating how the project will be accomplished. What sequence of work are you planning to ensure timely completion of the project? (i.e., what areas or work processes will be done first? next? last?) How many and what types of resources (personnel and equipment) will be assigned to the project?

10. List below the experience of the principal individuals of your business:

INDIVIDUAL’S NAME

PRESENT

POSITION

YEARS

OF EXP.

MAGNITUDE AND TYPE OF WORK

11. Explain your quality control plan to assure contract specifications are met. What is your plan for safety at the job site(s)? Identify the hazards specific to the site(s) and the types of work being performed and how you plan to mitigate the risks.

12. Remarks. Specify Box Numbers (Attach sheets if extra space is needed to fully answer any above question):

CERTIFICATION

I certify that all of the statements made by me are complete and correct to the best of my knowledge and that any person’s name as references are authorized to furnish the Forest Service with any information needed to verify my capability to perform this project.

13a. Certifying Official Name and Title

13b. Signature (Sign in ink) 14. DATE