A09_Attachment 3 - Experience Questionnaire.docx

EXPERIENCE QUESTIONNAIRE

Instructions: See Box 10, remarks, if extra space is needed to answer any item below. Mark X in the appropriate boxes.

1. Contractors Name, Address, Telephone No. & Email

2. Type of Business ___Company ___Co-Partner ___Non-profit

___Corporation ___Individual

3. Howmany years experience do you have in this line of work? ____________Years

4. How many years experience as a Prime Contractor___________ Subcontractor____________

5. List the projects your business has completed in the last 3 years from the solicitation issuance date

CONTRACT

NUMBER

AWARD

AMOUNT

COMPLETED

DATE CONTRACT

COMPLETED

6. List all of your firms current contract commitments

CONTRACT

NUMBER

AWARD

AMOUNT

COMPLETED

7a. Have you ever failed to complete any work awarded to you? ____yes __ _no

7b. Has work ever been completed by performance bond? ___yes __ _no

7. If "yes" to either item 7a or 7b specify location(s) and reason(s) why

8. Organization information available for this project:

a. Minimum # of employees: ____________ and Maximum # of employees: ______________

b. Are employees regularly on your payroll: ___yes __ _no

c. Specify equipment available for this contract:

1. Motorgrader:

Whay type of motorgrader is planned for this solicitation? _____________________________________________

Is this motorgrader owned, leased or subcontracted? __________________________________________________

What size of motorgrader? Please state the horsepower, weight and blade width. ___________________________

2. What type of equipment is going to be used to clean culverts and tail ditches? _____________________________

3. How many dump trucks will be used/obtained to support aggregate hauling and spreading operations to National Forest System Roads: __________________________________________________________________________

Are these dump trucks owned, leased or subcontracted? _______________________________________________

What size are these dump trucks? Please state the # of axles and hauling capacities in tons. __________________

d. Estimate rate of progress: (Miles per Day)

1. Blading: Minimum progress rate: ____________ Maximum progress rate: ____________

2. Ditching: Minimum progress rate: ____________ Maximum progress rate: ____________

3. Cleaning Culverts and Tail Ditches : Minimum progress rate: __________ Maximum progress rate: __________

Estimate rate of progress: (Tons per Day)

4. Spot Surfacing: Minimum progress rate: ______________ Maximum progress rate: ________________

e. Planning & Scheduling:

1. How do you intend to plan scheduling for other concurent projects listed in box 6.

f. Site Visit:

1. Have you visited the site and are you familiar with the work to be performed, condition of the roads, site accessibility, etc… to ensure succesful execution of all contract requirements at the quoted unit prices?

Please explain.

g. Safety & Traffic Control

1. Please explain the safety measures that you will put in place to ensure that site specific safety hazards have been considered adequate mitigation measures are in place for those hazards.

9. List the experience of the principal individuals of your business that will be used to perform this solicitation:

(Such as, motorgrader operator, other equipment operators, site superintendant, etc…)

10. REMARKS

CERTIFICATION: I certify that all of the statements made by me are complete and correct to the best of my knowledge and that any persons named as references are authorized to furnish the Forest Service with any information needed to verify my capability to perform this project:

Name: