Attachmetn 4 Experience Questionaire.doc

Attachment #4

EXPERIENCE QUESTIONNAIRE

Instructions: See Box 10, 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

__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 contractor_____ subcontractor___

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

NOTE: The description of work performed should be in sufficient detail for the Government to determine what the work included. (i.e. Type of HVAC Systems/controllers, duct work performed, quantities involved, construction disciplines involved, 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.

Project & Location ___________________________________________________________________________________

Contract Number:_______________________________ Award Amount: _____________________________________

Period of Performance and/or completion date: _____________________________________________________________

Client/Company’s Name/Address: _______________________________________________________________________

Contact Name and Telephone number: ___________________________________________________________________

Description of Services (refer to note in No. 5 Type of HVAC Systems/controllers, duct work performed, quantities involved, etc.) ____________________________________________________________________________________________________

Project & Location ___________________________________________________________________________________

Contract Number:_______________________________ Award Amount: _____________________________________

Period of Performance and/or completion date: _____________________________________________________________

Client/Company’s Name/Address: _______________________________________________________________________

Contact Name and Telephone number: ___________________________________________________________________

Description of Services (refer to note in No. 5 Type of HVAC Systems/controllers, duct work performed, quantities involved, etc.) _____________________________________________________________________________________________________

Project & Location ___________________________________________________________________________________

Contract Number:_______________________________ Award Amount: _____________________________________

Period of Performance and/or completion date: _____________________________________________________________

Client/Company’s Name/Address: _______________________________________________________________________

Contact Name and Telephone number: ___________________________________________________________________

Description of Services (refer to note in No. 5 Type of HVAC Systems/controllers, duct work performed, quantities involved, etc.)

Project & Location ___________________________________________________________________________________

Contract Number:_______________________________ Award Amount: _____________________________________

Period of Performance and/or completion date: _____________________________________________________________

Client/Company’s Name/Address: _______________________________________________________________________

Contact Name and Telephone number: ___________________________________________________________________

Description of Services (refer to note in No. 5 Type of HVAC Systems/controllers, duct work performed, quantities involved, etc.)

6. Experience: (MAY BE PRIME OR SUBCONTRACTOR) Certified Installer’s name (s): __________________________________________________________________________

Attach training certificate/training documentation for HVAC specific sytem to be installed (Specific system means --Mitsubishi unless “or equal” offered)

List 3 complete HVAC specific instllations: (Provide project information, Point of Contact and telephone number)

1. ______________________________________________________________________________________________

2. ______________________________________________________________________________________________

3. ______________________________________________________________________________________________

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

7b. Has work ever been completed by performance bond? __yes __ no

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

8. List the experience of the primary individuals to perform on proposed project

9. Information required to complete a responsibility determination of the apparent successful offeror (applicable if contract price over $100K) (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. Credit References

Materials/Services Provided

b. Banking Information.

Account No.

10. 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: