PastPerformanceQuestionaire.doc

EXPERIENCE AND PAST PERFORMANCE QUESTIONNAIRE

Instructions: See Box 11, REMARKS, if extra space is needed to answer any items below. Mark "X" in the appropriate boxes. Please list NA for inapplicable items.

____ Company

____ Corporation

____ Non-profit Organization

____ Co-partner

____ Individual

3. How many years of experience do you have in this line of work? ___________________

4. How many years of experience as a prime contractor? _________ subcontractor? ________

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

Contract Amount

Completed Name and Telephone Number to Contact For Information

6. List all of your firm's current contract commitments.

Contract Number Contract Amount

Completion Name and Telephone Number to Contact For Information

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 7c. If "yes" to either Question 7a. or 7b., please specify location(s) and reason(s):

8. 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:

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

10. Submit, as part of this proposal/quote, a proposed sequence of work/progress schedule.

11. Remarks:

CERTIFICATION: I certify that all of the statements made above are complete and correct to the best of my knowledge and that ny 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

ATTACHMENT B

Instructions: This form may be used to document your past performance. Forward this form to your reference(s). Request they complete the form and return it to the Contracting Officer before the quote due date and time.

RETURN TO: Ashley Witmer, Contract Specialist via email or mail:

Mailing Address:

Email:

Hoosier National Forest

ATTN: Ashley Witmer or ashleyawitmer@fs.fed.us

811 Constitution Ave

Bedford, IN 47421

PRESENT/PAST PERFORMANCE QUESTIONAIRE

SECTION A: CONTRACTOR INFORMATION

A. Contractor’s Name and Address:

B. Point of Contact

C. Phone Number:

D. Contract Number

E. Project Title:

F. Period of Performance:

G. Brief Description/ Scope of Services:

H. Authorization is hereby granted to provide the information requested in SECTION B of this questionnaire:

Signature of Authorized Offeror Representative Date Printed Name and Title of Authorized Offeror Representative

REFERENCE/RESPONDENT INFORMATION:

A. Name:

B. Position

C. Phone #

D. Address:

E. Relationship:

F. Date Questionnaire Completed:

PRESENT/PAST PERFORMANCE QUESTIONAIRE

RATING SCALE

CONTRACTOR’S OVERALL EVALUATION RATING

REMARKS: ________________________________________________________________________________________

(Attach additional sheets if necessary)