J-5_Contractor_Experience_Questionnaire_Form.pdf

EXPERIENCE QUESTIONNAIRE

INSTRUCTIONS: See Box 11, Remarks, if extra space is needed to answer any item below. Mark "X" in appropriate boxes.

1. CONTRACTOR NAME, ADDRESS AND TELEPHONE NUMBER

2. SUBMITTED TO (Office Name and Address)

3. BUSINESS

Υ Company Υ Co-partnership Υ Corporation Υ Individual Υ 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) sub-contractor ______?

6. List below the projects your business has completed within the last five (5) years which are similar in scope and scale to this job.

CONTRACT

AMOUNT

TYPE OF PROJECT DATE

COMPLETED

NAMES, 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:

NUMBER

DOLLAR

AMOUNT

NAME, ADDRESSS AND TELEPHONE

NO. OF BUSINESS/GOVERNMENT

AGENCY INVOLVED

AWARDED

(units)

PERCENT

COMPLETED

DATE

COMPLETED

8a. Have you ever failed to complete any work awarded to you? Υ Yes Υ No 8b. Has work ever been completed by performance bond? Υ Yes Υ No 8c. If "Yes" to either item 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 (2) Maximum number of employees:________

b. Are employees regularly on your payroll: Υ Yes Υ 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 PRESENT

POSITION

YEARS OF

EXPERIENCE

MAGNITUDE AND TYPE OF WORK

11. REMARKS - SPECIFY BOX NUMBERS (Attach sheets if extra space is needed to fully answer any of the above questions.)

12a. CERTIFYING OFFICIAL'S NAME AND TITLE

CERTIFICATION

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 District with any information needed to verify my capability to perform this project.

12B. SIGNATURE (Sign in ink) 13. DATE