A10_127EAS25R0004-Att5-ExperienceQuestionnaire.docx

United States Department of Agriculture

Forest Service

Rocky Mountain Acquisition Management

2150 Centre Ave., Bldg. E Fort Collins, CO 80526

United States Department of Agriculture Forest Service

USDA – Forest Service

EXPERIENCE QUESTIONNAIRE

(Ref. FSH 6309.31 and 41 USC 1)

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)

USDA Forest Service Attn: Matt Killian, Contract Specialist Email: matthew.killian@usda.gov

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 projects your business has completed within the last three years:

CONTRACT

AMOUNT

(6a)

TYPE OF PROJECT AND BRIEF DESCRIPTION

(6b)

DATE

COMPLETED

(6c) NAME, ADDRESS, AND TELEPHONE NO. OF OWNER/PERSON TO CONTACT FOR PROJECT INFORMATION (6d)

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

CONTRACT

NUMBER

(7a)

DOLLAR AMT.

OF AWARD

(7b)

NAME, ADDRESS, AND TELEPHONE NO. OF BUSINESS/GOVERNMENT AGENCY INVOLVED

(7c)

AWARDED

(Date) (7d)

PERCENT

COMPLETED

(7e)

ANTICIPATED COMPLETE DATE

(7f)

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: Yes No 8d. Did you look at the project site(s) on-the-ground? Yes No

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. Specify equipment available for this contract: __________________________________________________________________________

d. 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

(10a)

PRESENT

POSITION

(10b)

YEARS

OF EXP.

(10c)

MAGNITUDE AND TYPE OF WORK

(10d)

11. 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.

12. Contractor Inspection. Describe Contractor Self Inspection Procedures which you will use to insure 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 Forest Service with any information needed to verify my capability to perform this project.

14a. CERTIFYING OFFICIAL’S NAME AND TITLE

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