Att 1 Experience Questionnaire.pdf

USDA Forest Service

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 and Address) 3. BUSINESS [ ] Company [ ] Co-partnership [ ] Corporation [ ] Individual [ ] Non-profit Organization

4. How many years do you or your firm have in the services required under this solicitation?

5. How many years experience have you or your business had as a (a) prime contractor ____ and/or (b) sub-contractor ____ in the services required under this solicitation?

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

CONTRACT

AMOUNT

TYPE OF PROJECT DATE

COMPLETED

NAME, ADDRESS & TELEPHONE # OF OWNER/PERSON TO

CONTACT FOR PROJECT INFORMATION

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

CONTRACT

NUMBER

DOLLAR AMT.

OF AWARD

NAME, ADDRESS, AND TELEPHONE NO. OF

BUSINESS/GOVERNMENT AGENCY INVOLVED

AWARDED

(UNITS)

PERCENT

COMPLETE

DATE CONTRACT

COMPLETED

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:

(OVER)

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 item quantity per day):

(1) Minimum progress rate:________________ and (2) Maximum progress rate: _________________________

10. List below the experience of the principal individuals of your business: (Who will directly be involved in this contract?)

INDIVIDUAL’S NAME PRESENT POSITION YEARS OF

EXPERIENCE

MAGNITUDE AND TYPE OF WORK

11. REMARKS-SPECIFY BOX NUMBERS (Attach sheets if extra space is needed to fully answer any above question.):

NOTE: PLEASE PROVIDE ANY ADDITIONAL INFORMATION THAT WILL HELP EVALUATE YOUR

ABILITY TO SUCCESSFULLY COMPLETE THIS PROJECT.

CERTIFICATION

I certify that all of the statements made by me are complete and correct t 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

b. SIGNATURE (Sign in ink) 13. DATE

CERTIFICATION