Experience_questionnaire.pdf

CONTRACTOR QUESTIONNAIRE

Prior to award, the Contracting Officer must determine if the Contractor selected for the proposed award is responsible within the meaning of 41 CFR 1-1.1202. The primary factors which influence this determination are the firm's financial capacity and its references. The Government shall treat all information submitted on this form as confidential. Please complete all pages of this form and return to the Contracting Officer.

A. GENERAL INFORMATION

1. Name of Firm: ______________________________________________________

2. Address: ______________________________________________________

3. Telephone No. ______________________________________________________

4. Facsimile No. ______________________________________________________

5. Address at which accounts for this operation are kept, if different than location cited above.

B. PERFORMANCE and PAYMENT BOND INFORMATION

1. Name of Insurance Company supplying Performance and Payment Bonds:

2. Address: ___________________________________________________________

3. Name of Agent: ___________________________________________________________

4. Telephone No. of Agent ____________________________________________________

5. Your firm's Bonding capacity as authorized by Insurance Company for:

a. Single Project: __________________________________________________________

b. Aggregate Basis:_________________________________________________________

C. BANKING INFORMATION

1. Name of Bank: ___________________________________________________________

2. Address: ___________________________________________________________

3. Name of Account Representative: ____________________________________________

4. Telephone No. of Representative: ____________________________________________

D. INSURANCE INFORMATION

1. Name of Insurance Company: ________________________________________________

2. Type of Insurance provided: ________________________________________________

3. Address: ________________________________________________________________

4. Name of Agent: ___________________________________________________________

5. Telephone No. of Agent: ____________________________________________________

6. If more than one Insurance company is used, please provide the above information for each on an additional sheet of paper.

E. SAFETY DATA

1. Does your firm have a Standard Operating Procedure for Safety?

Yes _______ No _______

2. Does your firm have a policy letter dealing with Safety?

Yes _______ No _______

3. What was your accident rate for the last year? ___________________________________

4. What is your accident rate to date for this year?__________________________________

F. QUALITY CONTROL DATA

1. Does your firm have a Standard Operating Procedure for Quality Control?

Yes _____ No _____

2. Does your firm have a policy letter dealing with Quality Control?

Yes _____ No _____

G. ASBESTOS CONTRACTORS - (deleted)

H. EXPERIENCE DATA & REFERENCES

Please provide the following data for all projects with similar (or higher) dollar values and scopes of work completed within the past 3 years. If you can not provide at least 5 projects that meet these criteria, provide a list of all projects completed within the last 3 years. Attach additional references as required.

1a. Description of Work: ______________________________________________________

b. Company Name: _________________________________________________________

c. Address: ___________________________________________________________

d. Telephone No. ___________________________________________________________

e. Name of Contact: _________________________________________________________

f. Title of Contact: _________________________________________________________

g. Value of Project: _________________________________________________________

h. Completion Date: _________________________________________________________

2a. Description of Work: ______________________________________________________

b. Company Name: _________________________________________________________

c. Address: ___________________________________________________________

d. Telephone No. ___________________________________________________________

e. Name of Contact: _________________________________________________________

f. Title of Contact: _________________________________________________________

3a. Description of Work: ______________________________________________________

b. Company Name: _________________________________________________________

c. Address: ___________________________________________________________

d. Telephone No. ___________________________________________________________

e. Name of Contact: _________________________________________________________

f. Title of Contact: _________________________________________________________

4a. Description of Work: ______________________________________________________

b. Company Name: _________________________________________________________

c. Address: ___________________________________________________________

d. Telephone No. ___________________________________________________________

e. Name of Contact: _________________________________________________________

f. Title of Contact: _________________________________________________________

5a. Description of Work: ______________________________________________________

b. Company Name: _________________________________________________________

c. Address: ___________________________________________________________

d. Telephone No. ___________________________________________________________

e. Name of Contact: _________________________________________________________

f. Title of Contact: _________________________________________________________

List below all of your firm’s contractual commitments running concurrently with the work contemplated by this solicitation. (Use separate sheet for continuation if needed).

NAME, ADDRESS, AND TELEPHONE NUMBER OF

BUSINESS OR GOVERNMENT AGENCY

CONTRACT

NUMBER

DOLLAR

AMOUNT

PERCENT

COMPLETE

EXPECTED

COMPLETION

DATE

List below information for major subcontractors planned for this project.

NAME, ADDRESS, AND TELEPHONE NUMBER TYPE OF WORK

DOLLAR

AMOUNT

On a separate sheet provide a brief resume of principal individuals in your firm, including the proposed project manager and superintendent. Include at a minimum the individual’s name, present position, years of experience, years with your firm, and type of duties.

I. PAYMENTS

1. Partial or final payments made under the proposed contract will be issued in accordance with FAR 52.232-27 of the solicitation entitled Prompt Payment for Construction Contracts. For this reason, the Contractor must have either:

(a) Adequate capital in hand to purchase materials, meet weekly payrolls, and cover other job expenses, or

(b) Credit available from suppliers, banks, etc. for these purposes.

2. Please complete the following: I have adequate financial resources in hand to pay for:

(a) Materials __________ (b) Labor __________

(c) Other job expenses _________

I certify that the above information is correct.

Company Name of Offeror:

Printed Name of Signee:

Title of Signee:

Signature of Signee: