QUOTE_SUBMISSION_QUESTIONAIRE.docx

QUOTE SUBMISSION QUESTIONAIRE

☐ Completed Schedule of Services (pages2-4) with proposed pricing for a one-year Base Period and Four (4) one-year option periods.

☐ Quoter confirms the attached Performance Work Statement (PWS) has been thoroughly reviewed before submitting a quotation, including Quote Submission Instructions in Section 4.5.1 and Evaluation – Commercial Items in Section 4.3

☐ The active registration in the System for Award Management (SAM) - www.SAM.gov .

☐ Quoter confirms the provision FAR 52.212-3, the annual representations and certifications, has been electronically completed at www.SAM.gov. The complete provision is attached to PWS.

☐ Contract Federal Tax ID Number is provided:__________________________

☐ Contractor DUNS number is provided:_________________________

☐ A resume for each proposed Key Personnel and proposed substitute is provided (max 2 page allowed).

☐ A copy of the State of Montana license for each proposed Key Personnel is provided (1 page allowed).

☐ A copy of the State of Montana license for the proposed substitute(s) is provided (1 page allowed).

Proof of General Insurance, in accordance with FAR 52.228-5; AND Medical Insurance, in accordance with FAR 52.237-7, ☐ IS provided (1 page allowed each) OR ☐ CAN be provided before contract award.

Contractor’s Point of Contact (POC) Information is provided:

Name/Position: Email:

Phone: Fax:

☐ The following questions have been answered as provided below (maximum of 1 additional page allowed for each question, if necessary):

1. How will your company provide a qualified substitute, when necessary?

2. Do you have any other Job Corp experience? If so, where?

3. Within the past 5 years have you failed to complete any work awarded to you or been terminated for default or breach of contract? If yes, explain.

4. How many years of experience do your company and any key personnel have in regards to the requirements stated in this solicitation

☐ The following three (3) professional references of similar past work performance is provided:

1. Name: Organization:

Phone: Email:______________________________________

2. Name: Organization:

Phone: Email:______________________________________

3. Name: Organization:

Phone: Email:

☐ I certify that all of the information provided above is complete, true, and correct to the best of my knowledge.

Sign:______________________________________ Date:_______________________________________

AG-82A7-S-14-0018 Physician Services – Ouachita Job Corps Center Page 1 of 2