Experience_Questionnaire.docx

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, TELEPHONE NUMBER, EMAIL ADDRESS, DUNS AND TIN NUMBERS.

2. SUBMITTED TO (Office Name and Address)

AARON KRETZER

765 SOUTH MAIN

COLVILLE WA 99114

akretzer@fs.fed.us Fax: 1-888-489-2655

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

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

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 IF APPLICABLE AND PROVIDE YOUR RESPONSE TO BIOBASED PRODUCTS:

(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.

SAMPLE SUBMISSION OF PRICING AND ACCEPTANCE STATEMENT

1-SCHEDULE OF ITEMS:

Item No. 001; Vault Toilet Pump Service; estimated quantity 20; EA; Period of Performance is 06/22/2015 through 10/31/2015; Final delivery date is 10/31/2015.

PRICE: $_______

Item No. 002 Option; Vault Toilet Pump Service; estimated quantity 20; EA; Period of Performance is 04/01/2016 through 10/31/2016; Final delivery date is 10/31/2016.

PRICE: $_______

Item No. 003 Option; Vault Toilet Pump Service; estimated quantity 20; EA; Period of Performance is 04/01/2017 through 10/31/2017; Final delivery date is 10/31/2017.

PRICE: $_______

Item No. 004 Option; Vault Toilet Pump Service; estimated quantity 20; EA; Period of Performance is 04/01/2018 through 10/31/2018; Final delivery date is 10/31/2018.

PRICE: $_______

Item No. 005 Option; Vault Toilet Pump Service; estimated quantity 20; EA; Period of Performance is 04/01/2019 through 10/31/2019; Final delivery date is 10/31/2019.

PRICE: $_______

I, __________________________________agree with all terms, conditions, and provisions included in the solicitation AG-05G1-S-15-0060.