7 Experience Questionnaire.docx

EXPERIENCE QUESTIONNAIRE

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 __ Individual __Partnership __Corporation

DUNS No. __________________

3. Howmany years experience do you have in this line of work? ____Years

4. How many years experience as a prime contractor_____ subcontractor___

5. LIST OF THE MOST RELAVENT PROJECTS YOUR BUSINESS HAS COMPLETED WITHIN THE LAST 3 YEARS

NOTE: List only projects that are relevant to the work being solicited. The description of work performed should be in sufficient detail for the Government to determine what the work included. (i.e., what type of labor classifications were used, quantity of road or other type of similar work accomplished, type of equipment used, special safety requirements) Use of only a project title does not usually provide enough detail for the Government to make an evaluation.

Contract Number:______________________________________ Award Amount: _________________________________ Client/Company’s Name/Address: ________________________________________________________________________ Contact Name and Telephone number: ____________________________________________________________________ Description of Work Performed: _________________________________________________________________________ Subcontractors used: __________________________________________________________________________________ Date completed or scheduled for completion: ______________________________________________________________

Contract Number:______________________________________ Award Amount: _________________________________ Client/Company’s Name/Address: ________________________________________________________________________ Contact Name and Telephone number: ____________________________________________________________________ Description of Work Performed: _________________________________________________________________________ Subcontractors used: __________________________________________________________________________________ Date completed or scheduled for completion: ______________________________________________________________

Contract Number:______________________________________ Award Amount: _________________________________ Client/Company’s Name/Address: ________________________________________________________________________ Contact Name and Telephone number: ____________________________________________________________________ Description of Work Performed: _________________________________________________________________________ Subcontractors used: __________________________________________________________________________________ Date completed or scheduled for completion: ______________________________________________________________

Contract Number:______________________________________ Award Amount: _________________________________ Client/Company’s Name/Address: ________________________________________________________________________ Contact Name and Telephone number: ____________________________________________________________________ Description of Work Performed: _________________________________________________________________________ Subcontractors used: __________________________________________________________________________________ Date completed or scheduled for completion: ______________________________________________________________

Contract Number:______________________________________ Award Amount: _________________________________ Client/Company’s Name/Address: ________________________________________________________________________ Contact Name and Telephone number: ____________________________________________________________________ Description of Work Performed: _________________________________________________________________________ Subcontractors used: __________________________________________________________________________________ Date completed or scheduled for completion: ______________________________________________________________

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

6b. Has work ever been completed by the surety company? __yes __ no

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

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

8. Information required to complete a responsibility determination of the apparent successful offeror. (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. Creditor References

b. Banking Information.

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: