Experience Capability Statement 0555.doc

SOL NO: AG-4419-S-10-0555

Little Popple North Culvert Replacement Chequamegon-Nicolet National Forest

Eagle River/Florence District

(CIM-0913/0915-9EW-349-0913-01)

(This page must be included with quotation submission.)

Company Name

Date

Contractor’s Name

Company Address

Phone number

Fax number Cell phone number

E-mail address

Duns Number

Tax ID Number Instructions: Mark “X” in the appropriate boxes. Please list NA for inapplicable items.

1. Type of Business

(Please check appropriate line.)

Company

Corporation

Non-profit Organization

Co-partner

Individual

2. How many years of experience do you have in this line of work? ______________________

3. How many years of experience as a prime contractor? _________ subcontractor? ________

4. List the projects your business has completed in the last 3 years.

Contract

Amount

Completed Name and Telephone Number to

Contact for Information/Reference

5. List all of your firm’s current contract commitments.

Contract

Number Contract

Amount

Completion Name and Telephone Number to

Contact For Information/Reference

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

6c. If “yes” to either Question 6a. or 6b., please specify location(s) and reason(s):

7. Organization that will be available for this project:

a. Minimum No. of employees:_________ Maximum No. of employees:________

b. Are employees regularly on your payroll? ____yes ____no

c. If applicable, estimate rate of progress (i.e., acres per day):

Minimum progress rate: _______________ Maximum progress rate: ____________

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

9. Please list three references for like-kind work.

Name

Phone

1. ___________________________________

2. ___________________________________

3. ___________________________________

10. Please list equipment (make, model, year) that will be used:

1. _________________________________________________________________________

2. __________________________________________________________________________

3. __________________________________________________________________________

4. __________________________________________________________________________

5. __________________________________________________________________________ (add additional equipment on separate sheet)

11. Remarks:

CERTIFICATION: I certify that all of the statements made above 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.

Signature

Title

Date

PAGE