Experience.Questionaire.doc

EXPERIENCE/ PAST PERFORMANCE QUESTIONNAIRE Page 1 Instructions: See Box 9, remarks, if extra space is needed to answer any item below. Additional sheets may be attached.

1. Contractors Name, Address & Telephone No.

2. Type of Business

__Company __Co-Partner __Non-profit

__Corporation __Individual

3. How many years experience do you have in this line of work____Yrs

4. How many years experience as a prime contractor_____ subcontractor___

5. LIST OF PROJECTS YOUR BUSINESS HAS COMPLETED WITHIN THE LAST 5 YEARS

NOTE: The description of work performed should be in sufficient detail for the Government to determine what the work included.

Contract Number:______________________________________ Award Amount: _________________________________ Client/Company’s Name/Address: ________________________________________________________________________

Contact Name and Telephone number: ____________________________________________________________________ Description of Work Performed: _________________________________________________________________________

Date completed or scheduled for completion: ______________________________________________________________

Contract Number:______________________________________ Award Amount: _________________________________ Client/Company’s Name/Address: ________________________________________________________________________

Contact Name and Telephone number: ____________________________________________________________________ Description of Work Performed: _________________________________________________________________________

Date completed or scheduled for completion: ______________________________________________________________

Contract Number:______________________________________ Award Amount: _________________________________ Client/Company’s Name/Address: ________________________________________________________________________

Contact Name and Telephone number: ____________________________________________________________________ Description of Work Performed: _________________________________________________________________________

Date completed or scheduled for completion: ______________________________________________________________

Contract Number:______________________________________ Award Amount: _________________________________ Client/Company’s Name/Address: ________________________________________________________________________

Contact Name and Telephone number: ____________________________________________________________________ Description of Work Performed: _________________________________________________________________________

Date completed or scheduled for completion: ______________________________________________________________

6a. Have you ever failed to complete any work awarded to you? __yes __ no

___________________________________________________________________________________________Page 3

7. List the experience of the principal individuals of your business

8. REMARKS (Additional sheets may be attached to the experience questionnaire)

PLEASE LIST BELOW THE EQUIPMENT YOU PROPOSE TO USE FOR COMPLETION OF THIS PROJECT.

1. _____________________________________________________________________________________

2. ______________________________________________________________________________________

3. ______________________________________________________________________________________

4. ______________________________________________________________________________________

5. ______________________________________________________________________________________

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:

Name: