ATTACHMENT 5 EXPER QUEST.docx

AG-4568-S-12-0022 NFNC Road Maintenance IDIQ

EXPERIENCE QUESTIONNAIRE

Instructions: See Item No. 10, 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 __Corporation __Individual __Non-profit

3. How many years experience do you have in this line of work____Yrs

4. How many years experience as a prime contractor_____ subcontractor___

5. List the relevant current/past projects for your business in the last 3 years:

a. Project (Location): ____________________________________________________________________________________

Contract Amount $______________________________________ Period of Performance______________________________

Description of Services (i.e. type of road, length of road, equipment used, tasks performed, trades involved) _______________________________________________________________________________________________________

Name, Address & Telephone Number for Point of Contact for Information:

b. Project (Location): ____________________________________________________________________________________

Contract Amount $______________________________________ Period of Performance______________________________

Description of Services (i.e. type of road, length of road, equipment used, tasks performed, trades involved) _______________________________________________________________________________________________________

Name, Address & Telephone Number for Point of Contact for Information:

c. Project (Location): ____________________________________________________________________________________

Contract Amount $______________________________________ Period of Performance______________________________

Description of Services (i.e. type of road, length of road, equipment used, tasks performed, trades involved) _______________________________________________________________________________________________________

Name, Address & Telephone Number for Point of Contact for Information:

Attach supplemental sheets if space is not sufficient above

d. Project (Location): ____________________________________________________________________________________

Contract Amount $______________________________________ Period of Performance______________________________

Description of Services (i.e. type of road, length of road, equipment used, tasks performed, trades involved) _______________________________________________________________________________________________________

Name, Address & Telephone Number for Point of Contact for Information:

e. Project (Location): ____________________________________________________________________________________

Contract Amount $______________________________________ Period of Performance______________________________

Description of Services (i.e. type of road, length of road, equipment used, tasks performed, trades involved) _______________________________________________________________________________________________________

Name, Address & Telephone Number for Point of Contact for Information:

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

If "yes" to the question above, specify location(s) and reason(s) why

7. Contract Management:

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

c. Specify contractor owned equipment (indicate size & capacity) to be used for this contract

d. Tasks to be subcontracted:

e. Provisions to secure additional equipment or personnel:

f. Past experience in managing multiple contracts simultaneously:

(PLEASE NOTE IF ADDITIONAL SHEETS MAY BE ATTACHED TO SUPPLEMENT THIS FORM)

8. Small Business Subcontracting Efforts (List proposed subcontractors to be used on the contract and indicate the type of business (i.e. Small Business, Women Owned, Small Disadvantaged)

9. Geographical Proximity. The contractor’s is located ________ miles from the ___________________ Ranger District Office

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

11. Information required to complete a financial responsibility determination if the apparent successful offeror.

a. Credit References

b. Banking Information.

12. REMARKS: (PLEASE NOTE ADDITIONAL SHEETS MAY BE ATTACEHD TO SUPPLEMENT THIS FORM)

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