LPTA_Factor_3_form.pdf

AG-0116-S-14-0021

Technical Evaluation Factor 3 Form

Co-Located Sitka Office Renovation

NOTE: This information and Questionnaires are due not later than 10 days prior to the proposal due date.

(3) Technical Experience. (Prime OR Subcontractor) – Submit at LEAST one (1) but not more than three

(3) contracts over the past three (3) years that consists of quarry operations that includes blasting.

Briefly describe how you meet the Factor:

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Cont:…

PRIME CONTRACTOR INFORMATION:

By completing this form you are representing that the above information is accurate and true as of the date of the signature.

Company Name: ___________________________________

Individuals Name: _________________________________ Phone: ______________________

Signature of Individual: _____________________________ Date: _______________________

E-mail Address: _____________________________________________

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Technical Evaluation Factor 3 Form

Contract Details

Offeror Name: ___________________________________________________________________

List the information for the most recent contracts for this evaluation factor. Provide the survey to the

Owner/Organization. (Surveys must be submitted directly to FS by the Owner/Agency)

Name of Contractor Accomplishing this Work: __________________________________________

Project Name/Number: _________________________________________________

Project Contract Number:____________________________________

Owner/Organization Name: _______________________________________________

Address: ______________________________ P.O. Box/Street

City, State, Zip Code

Owner/Organization Point of Contact: _______________________________________ Name

Owner/Organization Phone Number: _______________________________________

Contract Value: $_________________ Performance Period: ____________________________

Quarry operations that includes blasting.:

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