Attachment__11.pdf

USDA Forest Service (3/03)

EXPERIENCE QUESTIONNAIRE

Instructions: See Box 11, Remarks, if extra space is needed to answer any item below. Mark “x” in appropriate boxes.

1. Contractor Name, Address, and Telephone Number

2. Submitted to (Office Name & Address)

3. Business q Company Partnership q Corporation Individual q Non-profit Organization

4. How many years do you or your firm have in the line of work contemplated by this solicitation

5. How many years experience in contracting have you or your business had as a (a) prime contractor ________ and/or

(b) sub-contractor ______?

6. List below the projects your business has completed within the last three years:

Contract Amount

Type of Project

Date

Completed

Name, Address, and Telephone No. of Owner/Person to Contract for Project Information

7. List below all of your firm’s contractual commitments running concurrently with the work contemplated by this solicitation:

Contract Amount

Dollar Amt Of Award

Name, Address, and Telephone No. of Business/Government Agency Involved

Awarded (Units)

Percent Completed

Date Contract Complete d

8a. Have you ever failed to complete any work awarded to you? _____ Yes _____ No 8b. Has work ever been completed by performance bond? _____ Yes _____ No 8c. If “Yes” to either item 8a or 8b specify location(s) and reason(s) why:

9. Organization and work that will be available for this project:

a. (1) Minimum number of employees:__________ and a (2) Maximum number of employees:__________

b. Are employees regularly on your payroll? _____ Yes _____ No

c. Specify equipment available for this contract:_______________________________________________

d. Estimate rate of progress below (such as 2.0 acres/man/day):

(1) Minimum progress rate: __________ and (2) Maximum progress rate: __________

e. Describe the safety plan and procedures employed by your firm. Specifically address: 1) how maximum safety is ensured for both employees and the public who may be on the work site during contract performance, 2) First Aid and evacuation plans in the event of an illness or injury.

Use a separate sheet of paper if necessary.

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

Individual’s Name Present Position Years of Exp.

Magnitude and Type of Work

11. Remarks—Specify Box Numbers (Attach sheets if extra space is needed to fully answer any above questions):

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.

12a.Certifying Official’s Name and Title 12b. Signature (Sign in Ink) 13. Date