Responsibility Questionnaire.doc
DOC document 45 KB Posted
- Solicitation number
- AG-56A1-S-12-0002
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Responsibility Questionnaire
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Text version
QUESTIONNAIRE FOR RESPONSIBILITY DETERMINATION
Instructions: See #11, REMARKS, if extra space is needed to answer any items below. Mark "X" in the appropriate boxes. Please list “NA” for inapplicable items. This questionnaire will be used for the sole purpose of assisting the Forest Service in making a responsibility determination pursuant to FAR Part 9.
| 1. Contractor's Name, Address & Telephone Number |
| 2. Type of Business |
____ 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 to the one in this solicitation that your business has completed in the last 5 years.
Contract Amount
| Type of Project |
| Date |
Completed Name and Telephone Number to Contact For Information
6. List your firm's current contract commitments.
Contract Number Contract Amount
| Type of Project |
| Est. Date of |
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.
| Individual's Name |
| Present Position |
| Years Experience |
| Type of Work |
10. If subcontractors will be used, identify the type and approximate percentage of work they will be performing on this project:
11. Remarks:
CERTIFICATION: I certify that all of the statements made above 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.
Signature Title Date
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