ATT5_EXP QUEST.doc

AG-4568-S-10-0001

EXPERIENCE QUESTIONNAIRE

Instructions: Indicate in Box 11, remarks, if extra space is needed to answer any item below. Mark X in the appropriate boxes.

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 contractpr_____ subcontractor___

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

CONTRACT

NUMBER

AWARD

AMOUNT

COMPLETED

DATE CONTRACT

COMPLETED

6. List all of your firms current contract commitments

CONTRACT

NUMBER

AWARD

AMOUNT

COMPLETED

7a. Have you ever failed to complete any work awarded to you? __yes __ no

7b. Has work ever been completed by performance bond? NOT APPLICABLE

7. If "yes" to either item 7a specify project(s) and reason(s) why

8. If large company, state which department that will be available for this project:

a. Minimum No. of employees: and Maximum No. of employees to be used for this contract:

b. Are employees regularly on your payroll: __yes __ no

c. Specify equipment available for this contract:

d. Estimate rate of progress (i.e., # pages per day):

1. Minimum progress rate: Maximum progress rate

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

11. REMARKS

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:

ATTACHMENT 5