A06-EXPERIENCE_QUESTIONNAIRE.pdf

EXPERIENCE QUESTIONNAIRE

INSTRUCTIONS: See Box 11, 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) 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 experience in contracting have you or your business had as a (a) prime contractor ____ and/or (b) sub-contractor ____?

6. List below the projects your business has completed within the last three years that is the same as the work requested:

CONTRACT

AMOUNT TYPE OF PROJECT

DATE

COMPLETED

NAME, ADDRESS, AND TELEPHONE NO. OF

OWNER/PERSON TO CONTACT FOR PROJECT

INFORMATION

7. List below all 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 8c. If “Yes” to either item 8a or 8b specify location(s) and reason(s) why:

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

a. (1) Minimum number of employees: _____ and a (2) Maximum number of employees: ______?

b. Are employees regularly on your payroll: Yes No

c. Estimate rate of progress below (such as 2.0 acres/man/day)

(1) Minimum progress rate: ________________________________ and (2) maximum progress rate: ________________________

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. List all the equipment (including vehicles) you plan to use on this contract. Provide a detailed description of the equipment.

Additional space is provided on page 2 if nessessary:

Solicitation 140L4322Q0125

BLM OR-ST OFC PROC MGMT BR(OR952)

1220 SW 3rd Avenue, 12th Floor

PORTLAND OR

12. Contractor Inspection. Describe Contractor Self Inspection Procedures which you will use to ensure quality for this contract.

13. 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 Bureau of Reclamation with any information needed to verify my capability to perform this project.

12a. CERTIFYING OFFICIAL’S NAME AND TITLE

b. SIGNATURE (Sign in ink) 13. DATE

EVALUATION QUESTIONNAIRE (Continued)

ANSWERS MUST BE RETURNED WITH QUOTE FOR CONSIDERATION

2. Record of Past Performance (Section 6 Continued). List additional relevant contracts you have had over the last three years. Include the name of the project, who the contract was with (agency or firm name), address, dates, and phone number of at least one reference per contract that could be contacted regarding these contracts.

3. Labor and State Compliance. List any contracts in the last three years which had Labor Compliance issues (MSPA, pay issues, etc.) with an explanation of the circumstances, including what action you took to avoid a recurrence. List how long you have been in the state in which you are preceding as a business. List all state account numbers (example: for Washington State, you are required to have a UBI license, etc.). If you did all the work yourself, state so.

4. Have you visited the site? ___ YES ___ NO

Solicitation 140L4322Q0125