AG-9702-S-10-0276_Present_Past Perf Org Exp Questionnaire--10 Jun 10.doc

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RECOVERY - Forestwide Recreation Site Host and Restroom Facility Improvements: Toilet Building Door and Jam Replacement, Prescott National Forest, Prescott Arizona, County of Yavapai
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AG-9702-S-10-0276
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US FOREST SERVICE SOLICITATION NO. AG-9702-S-10-0276 PAST PERFORMANCE QUESTIONAIRE

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SOW_rev060910.doc DOC document
AG-9702-S-10-0276_Combined Synopsis Solicitation--27 May 10.doc DOC document
Revised Schedule of Items-DoorRepl.xls XLS spreadsheet

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PRESENT/PAST PERFORMANCE & ORGANIZATIONAL EXPERIENCE QUESTIONNAIRE

SOLICITATION NO. AG-9702-S-10-0276

PROJECT TITLE: Recovery - Forestwide Recreation Site Host and Restroom Facility Improvements: Toilet Buildings Door and Jam Replacement, Prescott National Forest, Prescott Arizona, County of Yavapai

1. CONTRACTOR/OFFEROR’S NAME, ADDRESS, & TELEPHONE NUMBER

2. BUSINESS TYPE

[ ] COMPANY [ ] INDIVIDUAL

[ ] CORPORATION

[ ] CO-PARTNERSHIP

[ ] NON-PROFIT ORGANIZATION

3. HOW MANY YEARS DOES YOUR BUSINESS HAVE IN THE LINE OF WORK AS REQUIRED BY THIS SOLICITATION?

4. HOW MANY YEARS EXPERIENCE IN CONTRACTING HAS YOUR BUSINESS HAD AS A PRIME CONTRACTOR AND/OR SUB-CONTRACTOR ? IS THIS TIME CONCURRENT? .

5. LIST BELOW THE SIMILAR (SCOPE, SIZE, COMPLEXITY) PROJECTS (NO MORE THAN SEVEN) YOUR BUSINESS HAS COMPLETED WITHIN THE LAST THREE YEARS:

CONTRACT NUMBER & AWARD AMOUNT
PROJECT LOCATION
PERFORMANCE PERIOD
NAME, ADDRESS & TELEPHONE NUMBER OF OWNER/PERSON TO CONTACT FOR INFORMATION

6. LIST BELOW SIMILAIR (SCOPE, SIZE, COMPLEXITY) PROJECTS (NO MORE THAN SEVEN) YOUR BUSINESS IS WORKING ON CURRENTLY :

CONTRACT NUMBER & AWARD AMOUNT
PROJECT LOCATION
PERFORMANCE PERIOD
NAME, ADDRESS & TELEPHONE NUMBER OF OWNER/PERSON TO CONTACT FOR INFORMATION

7a. HAVE YOU EVER FAILED TO COMPLETE ANY WORK AWARDED TO YOU? [ ] YES [ ] NO

7b. HAVE YOU EVER RECEIVED LESS THAN SATISFACTORY PERFORMANCE RATINGS? [ ] YES [ ] NO

7c. IF "YES" TO EITHER ITEM 7a OR 7b, SPECIFY CONTRACT(S), REASON(S) AND PROVIDE NAME, ADDRESS & TELEPHONE NUMBER OF OWNER/PERSON TO CONTACT FOR INFORMATION:

(CONTINUED)

8. WORKERS AND/OR EQUIPMENT THAT WILL BE MADE AVAILABLE FOR THIS PROJECT:

a.(1) MINIMUM NO. OF EMPLOYEES:___________AND a.(2) MAXIMUM NO. OF EMPLOYEES__________

b. ARE EMPLOYEES REGULARLY ON YOUR PAYROLL: [ ] YES [ ] NO

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

NAME (FIRST & LAST)
POSITION/TITLE
YEARS/MONTHS OF EXPERIENCE WITH COMPANY
MAGNITUDE OF PROJECTS/TYPE OF WORK

10. ADDITIONAL REMARKS – REFERENCE SPECIFIC BOX NUMBERS:

CERTIFICATION: I CERTIFY THAT ALL OF THE STATEMENTS MADE BY ME ARE COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND
11a. CERTIFYING OFFICIAL'S PRINTED NAME & TITLE
THAT ANY PERSON(S) NAMED AS REFERENCE(S) IS/ARE AUTHORIZED TO FURNISH THE USDA FOREST SERVICE WITH INFORMATION NEEDED TO VERIFY MY CAPABILITY
11b. SIGNATURE (USE BLACK INK)

X

TO SUCCESSFULLY PERFORM THIS PROJECT.
11c. DATE (MONTH/DAY/YEAR):

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