Experience Capability Statement 0685.doc
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- Solicitation number
- AG-4419-S-10-0685
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Experience Capability Statement 0685
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AG-4419-S-10-0685
Lost Lake Organizational Camp Restoration and Rehabilitation Chequamegon-Nicolet National Forest
(CIM-0900-2F-32-0913-02)
(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
| Type of Project |
| Date |
Completed Name and Telephone Number to
Contact for Information/Reference
5. List all of your firm’s current contract commitments.
Contract
Number Contract
Amount
| Type of Project |
| Est. Date of |
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, specify equipment available for this contract:
8. List the experience of the principal individuals of your business.
| Individual’s Name |
| Present Position |
| Years Experience |
| Type of Work |
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
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