Attach-04-Experience_Questionnaire.pdf

SOLICITATION NO AG-82D7-S-17-0024

GRAND MESA NATIONAL FOREST

VISITOR CENTER WATER SYSTEM IMPROVEMENTS

Attachment 4

EXPERIENCE

QUESTIONNAIRE

1. CONTRACTOR NAME, ADDRESS AMD PHONE#

2. SUBMITTED TO (Office Name & Address)

USDA Forest Service White River National Forest 900 Grand Ave Glenwood Springs, CO 81601

3. BUSINESS:

___ Company ___ Co-partnership ___ Corporation ___ Individual __ Non-profit Organization

4. How many years of experience 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 FIRM HAD AS A:

PRIME CONTRACTOR AND/OR 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, & PHONE OF OWNER PERSONS TO

CONTACT FOR PROJECT INFORMATION

7. LIST BELOW ALL OF YOUR CONTRACTUAL COMMITMENTS RUNNING CONCURRENTLY WITH THE

WORK CONTEMPLATED BY THIS PROJECT:

CONTRACT

NUMBER AMOUNT

OF AWARD

NAME, ADDRESS & PHONE # OF

BUSINESS/GOVERNMENT

AGENCY INVOLVED

AWARDED

(UNITS)

PERCENT

COMPLETED

DATE COMPLETED

VISITOR CENTER WATER SYSTEM IMPROVEMENTS

8. (A) DESCRIBE A SITUATION WHERE THE CONTRACT PERFORMANCE PERIOD WAS NOT MET AND

HOW IT WAS RESOLVED.

(B) DESCRIBE A SITUATION WHERE A PRICE CHANGE TO A CONTRACT WAS REQUESTED AND HOW IT

WAS RESOLVED.

(C) DESCRIBE A SITUATION WHERE A WARRANTY ISSUE WAS RAISED BY THE OWNER AND HOW IT WAS

RESOLVED.

(D) DESCRIBE A SITUATION WHERE A PROBLEM WAS ENCOUNTERED AND ANY CORRECTIVE ACTIONS TAKEN

TO PREVENT A RECURRENCE.

9. LIST BELOW THE EXPERIENCE OF THE PRINCIPAL INDIVIDUALS OF YOUR BUSINESS:

INDIVIDUAL'S NAME

PRESENT

POSITION

YEARS

OF EXP.

MAGNITUDE AND TYPE OF WORK

VISITOR CENTER WATER SYSTEM IMPROVEMENTS

10. REMARKS: SPECIFY BOX NUMBERS (Attach sheets if extra space is needed to fully answer any of the 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.

11a. CERTIFING OFFICIAL'S

NAME AND TITLE

11 b. SIGNATURE (Sign in Black Ink)

12. DATE