Attachment 2 in MS Word Formatrtf.rtf

ROAD REPAIRS ON THE EL YUNGUE NATIONAL FOREST IN PUERTO RICO IFB AG-4146-S-12-0031

ATTACHMENT 2 –Responsibility Determination Questionnaire Instructions: See Box 11, 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. Howmany years experience do you have in this line of work____Yrs

4. How many years experience as a prime contractor_____ subcontractor___

LIST OF PROJECTS YOUR BUSINESS HAS COMPLETED WITHIN THE LAST 3 YEARS

NOTE: The description of work performed should be in sufficient detail for the Government to determine what the work included. (i.e. Type of road work, lengths, quantities, equipment used, Use of only a project title does not usually provide enough detail for the Government to make an evaluation.

Project & Location ________________________________________________________________________________________________ Contract Number:_______________________________ Award Amount: ________________________________________________ Period of Performance and/or completion date: ________________________________________________________________________ Client/Company’s Name/Address: __________________________________________________________________________________ Contact Name, email and Telephone number: ________________________________________________________________________ Description of Services (refer to note in No. 5 type of road work) ______________________________________________________________________________________________________________ Project & Location ________________________________________________________________________________________________ Contract Number:_______________________________ Award Amount: ________________________________________________ Period of Performance and/or completion date: ________________________________________________________________________ Client/Company’s Name/Address: __________________________________________________________________________________ Contact Name, email and Telephone number: ________________________________________________________________________ Description of Services (refer to note in No. 5 type of road work) ______________________________________________________________________________________________________________ Project & Location ________________________________________________________________________________________________ Contract Number:_______________________________ Award Amount: ________________________________________________ Period of Performance and/or completion date: ________________________________________________________________________ Client/Company’s Name/Address: __________________________________________________________________________________ Contact Name, email and Telephone number: ________________________________________________________________________ Description of Services (refer to note in No. 5 type of road work)) ______________________________________________________________________________________________________________ Project & Location ________________________________________________________________________________________________ Contract Number:_______________________________ Award Amount: ________________________________________________ Period of Performance and/or completion date: ________________________________________________________________________ Client/Company’s Name/Address: __________________________________________________________________________________ Contact Name, email and Telephone number: ________________________________________________________________________ Description of Services (refer to note in No. 5 type of road work)) ______________________________________________________________________________________________________________ 6a. Have you ever failed to complete any work awarded to you? __yes __ no 6b. Has work ever been completed by performance bond? __yes __ no

6. If "yes" to either item 6a or 6b specify location(s) and reason(s) why

7. List the experience of the primary individuals to perform on proposed project

INDIVIDUALS NAME

PRESENT POSITION

DEGREE/YRS EXP

TYPE OF WORK

8. Financial References. (Additional information may be requested once a contractor is selected for award.. Moreover, the contractor might need to provide additional authorization from a creditor to grant access.)

a. Credit References Company Name/Address Point of Contact Telephone number Materials/Services Provided

b. Banking Information.

Company Name/Address Point of Contact Telephone number Account No.

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

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:

Title:

Date:

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:

Title:

Date: