Tech Capability_Experience_ Performance Questionnaire.doc

TECHNICAL CAPABILITY, EXPERIENCE AND PAST/PRESENT PERFORMANCE QUESTIONNAIRE

Instructions: Complete by inserting information or Xing box, as indicated. If extra space is needed to complete an item, use the remarks block (indicate item number in remarks block) .

1. Contractor Name, Address, and Telephone Number

DUNS Number:

FEDERAL TAX ID NO.:

2. Submitted to (Office Name & Address)

George Washington & Jefferson National Forest

Attn: Sherry D. Helmick 5162 Valleypointe Parkway

Roanoke VA 24019-3050

RE: Solicitation #AG-3395-S-11-0020

3. Business

· Company ( 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? ________ Years

5. How many years experience in contracting have you or your business had as a (a) prime contractor ________ and/or

(b) sub-contractor ______ for same/similar services.

6. List below the projects your business has completed within the last three years (continue on separate sheet if necessary):

Contract

Amount

Completed Point of Contact, Business/Agency Name, Street Address, Email address, Telephone Number and Fax Number

7. List below all of your firm’s contractual commitments running concurrently with the work contemplated by this solicitation (continue on separate sheet if necessary):

Contract

Amount

(Units) Percent

Completed Date Contract to be

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

8c. If “Yes” to either item 8a or 8b specify location(s) and reason(s) why (continue on separate sheet if necessary):

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 employees regularly on your payroll? _____ Yes _____ No

c. Provide proposed work schedule, including start and stop dates, estimated number of days of work/production rate, such as acres/day, and labor crew.

d. Describe THE SAFETY MEASURES AND PROCEDURES employed by your firm. Specifically address: 1) how maximum safety is ensured for both employees and the public who may be on the work site during contract performance, 2) transportation safety for employees to and from work, and 3) First Aid and evacuation plans in the event of an illness or injury.

Use a separate sheet of paper if necessary.

10. List below the major equipment that will be utilized full time on this project:

Capacity, etc

11. List below the experience of the principal individuals of your business:

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

12a.Certifying Official’s Name and Title (Printed/Typed)