J-6_Offeror_Experience_Questionnaire.pdf

(Expires 7/31/04)

USDA Forest Service

EXPERIENCE QUESTIONNAIRE

(Ref. FSH 6309.31 and 41 USC 11) Instructions: See Box 11, remarks, if extra space is needed to answer any of them below.

Mark “X” in appropriate boxes.

1. CONTRACTOR NAME, ADDRESS AND TELEPHONE NUMBER

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) subcontractor_____

6. List below the projects your business has completed within the last three years.

CONTRACT

AMOUNT

TYPE OF PROJECT

DATE

COMPLETED

NAME, ADDRESS AND TELEPHONE NO. OF OWNER/PERSON TO

CONTACT FOR PROJECT INFORMATION

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

AMOUNT

DOLLAR AMT.

OF AWARD

NAME, ADDRESS AND TELEPONE NO. OF

BUSINESS/GOVERNMENT AGENCY INVOLVED

AWARDED

(UNITS)

PERCENT

COMPLETED

DATE

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 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 employee regularly on you payroll: [ ] Yes [ ] No

c. Specify equipment available for this contract:_________________________________________________________________________

d. Estimated rate of progress below ( such as 20 acres/man/day):

(1) Minimum progress rate:___________ and (2) Maximum progress rate___________

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

11. REMARKS - SPECIFY BOX NUMBERS

(Attach sheets if extra space is needed to fully answer any above questions:)

CERTIFICATION

12a. CERTIFYING OFFICAL’S NAME AND TITLE

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.

b. SIGNATURE (Sign in ink) 13. DATE