ATT 4 - EXPERIENCE QUESTIONNAIRE - RFQ 1291S820Q0045.pdf

USDA – Forest Service

EXPERIENCE QUESTIONNAIRE

(Ref. FSH 6309.31 and 41 USC 1)

INSTRUCTIONS: See Box 11, Remarks, if extra space is needed to answer any questions below. Mark “X” in appropriate boxes.

1. CONTRACTOR NAME, ADDRESS, AND TELEPHONE NO.

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 line of work contemplated by this solicitation?

5. How many years of experience in contracting have you or your business had as a (a) prime contractor and/or (b) sub-contractor ?

6. List below the projects your business has completed within the last three (3) years:

Factor 1 – Relevant Prior Experience and Past Performance

CONTRACT

AMOUNT

TYPE OF PROJECT DATE

COMPLETED

NAME, ADDRESS, AND TELEPHONE NO. 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:

NUMBER

DOLLAR AMT.

OF AWARD

NAME, ADDRESS, AND TELEPHONE NO. OF

BUSINESS/GOVERNMENT AGENCY INVOLVED

AWARDED

(Units)

PERCENT

COMPLETED

DATE

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:

Previous edition is obsolete (OVER)

FS-6300-27 (3/00)

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

10. List below the experience of the principal individuals of your business:

INDIVIDUAL’S NAME PRESENT

POSITION

YEARS

OF EXP. MAGNITUDE AND TYPE OF WORK

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 name as references are authorized to furnis 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

(Use Additional Sheets As Needed)