Attachment3-UpdatedQuestionnaire.pdf

Experience Questionnaire

Response Forms Page 1 of 2

Zigzag Ranger District Janitorial

EXPERIENCE AND PAST PERFORMANCE QUESTIONNAIRE

Instructions: Please use spaces below to respond to evaluation criteria. Additional or supplementary pages may also be submitted. Please list N/A for inapplicable items.

1. Quoter's Name, Address, Email, Telephone Number & DUNS Number 2. Type of Business

Name: ____ Company

____ Corporation

____ Partnership

____ Individual / Sole

Proprietor / Owner-Operator

Address:

Email:

Telephone:

DUNS #:

Name of proposed janitor(s) (on-site routine service provider(s)):

Name and title of any other proposed persons (inspectors, supervisors, managers, etcetera):

Relevant Experience of Janitorial Service Provider(s):

Relevant Experience of Contractor (as prime contractor or employer of janitorial service providers, if applicable):

Zigzag Ranger District Janitorial Experience Questionnaire

Response Forms Page 2 of 2

Past Performance References: Space is given for up to three each (Janitor(s) and supervisory personnel) as applicable; please add more space if needed.

Reference Name and

Company / Agency

Reference Contact Phone

Number

Description of Services Performed

Have you ever failed to complete any work awarded to you? ____ YES ____ NO

If "yes", please specify location(s) and reason(s):

Understanding of the Requirement: Did you visit the site? If not, how did you obtain information about the site sufficient to quote?

CERTIFICATION: By submission of this form the quoter certifies that all of the statements made above are complete and correct to the best of the quoter’s 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/Title: ____________________________/_________________________

Signature: ___________________________ Date: _______________________