Attachment 15 - Experience Questionnaire.pdf
PDF 160 KB Posted
- Solicitation number
- 127EAT24Q0009
- Issued by
-
Department of Agriculture Forest Service
About this file
This solicitation is for insecticide application services on 287 oak trees in the Cleveland National Forest. The U.S. Department of Agriculture Forest Service is seeking quotes to apply carbaryl contact insecticide to coast live oak trees greater than 14 inches in diameter at breast height to prevent goldspotted oak borer attacks. The work location is on the Palomar Ranger District in San Diego County, California. The period of performance is approximately 12 days from May 6, 2024 to May 22, 2024 for the base year with four option years. This is a 100% small business set-aside for NAICS code 115310 with a size standard of $34 million. Quotes are due by April 1, 2024 at 5:00 p.m. Pacific Time and will be evaluated based on technical capability, price, and past performance.
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Experience Questionnaire
1. Contractor Name, Address, Telephone Number, and Email Address:
DUNS or UEI: __________________ Small Business: Yes No
Primary NAICS Code: _____________
2. Do you have a California Qualified Applicator License or Certificate (QAL/QAC)? Yes No
3. How many years of experience do you or your company have in performing insecticide spraying services?
4. Estimate rate of progress (Such as acres/day, miles/day, or other rate):
Minimum progress rate: Maximum progress rate:
5. Organization that will be available for this work:
a. Minimum number of employees: and Maximum number of employees:
b. Are employees regularly on your payroll? Yes No
6. Please provide references for the last three (3) companies you have performed insecticide service:
Company and Point of Contract Email Address Phone Number
7. List the name (s) of the key personnel who will be performing the insecticide spraying services:
8. List below the experience of the key personnel who will be performing the work:
Individual’s Name Present Position Years of Experience
Type of Work
9. Past Performance - List below the projects your business has completed within the last three (3) years which are similar in scope and scale to this job:
Contract Number Contract Amount Location of Work Names, Telephone No., and Email of Owner/Person to contact for Project Information
Description of Project
Contract Number Contract Amount Location of Work Names, Telephone No., and Email of Owner/Person to contact for Project Information
Description of Project
Contract Number Contract Amount Location of work Names, Telephone No., and Email of Owner/Person to contact for Project Information
Description of Project
10. List below all of your firm's contractual commitments running concurrently with the work contemplated by this solicitation:
Contract # Dollar Amount Name, Tel, Email of Business/Govt Agency Involved
Location of work When will contract be completed?
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 Government with any information needed to verify my capability to perform this project.
13a. CERTIFYING OFFICIAL'S NAME AND TITLE
13b. SIGNATURE 14. DATE
| 1 Contractor Name Address Telephone Number and Email Address: |
| DUNS or UEI: |
| Primary NAICS Code: |
| 2 Do you have a California Qualified Applicator License or Certificate QALQAC YesNo: |
| 3 How many years of experience do you or your company have in performing insecticide spraying services: |
| 4 Estimate rate of progress Such as acresday milesday or other rate Minimum progress rate Maximum progress rate: |
| undefined: |
| undefined_2: |
| Minimum number of employees: |
| and Maximum number of employees: |
| Are employees regularly on your payroll: |
| Yes: |
| Company and Point of ContractRow1: |
| Email AddressRow1: |
| Phone NumberRow1: |
| Company and Point of ContractRow2: |
| Email AddressRow2: |
| Phone NumberRow2: |
| Company and Point of ContractRow3: |
| Email AddressRow3: |
| Phone NumberRow3: |
| 7 List the name s of the key personnel who will be performing the insecticide spraying services: |
| Individuals NameRow1: |
| Present PositionRow1: |
| Years of ExperienceRow1: |
| Type of WorkRow1: |
| Contract NumberRow1: |
| Contract AmountRow1: |
| Location of WorkRow1: |
| Names Telephone No and Email of OwnerPerson to contact for Project InformationRow1: |
| Description of Project: |
| Contract NumberRow1_2: |
| Contract AmountRow1_2: |
| Location of WorkRow1_2: |
| Names Telephone No and Email of OwnerPerson to contact for Project InformationRow1_2: |
| Contract NumberRow1_3: |
| Contract AmountRow1_3: |
| Location of workRow1: |
| Names Telephone No and Email of OwnerPerson to contact for Project InformationRow1_3: |
| Description of ProjectRow1: |
| Description of Project_2: |
| Contract Row1: |
| Dollar AmountRow1: |
| Name Tel Email of BusinessGovt Agency InvolvedRow1: |
| Location of workRow1_2: |
| When will contract be completedRow1: |
| Contract Row2: |
| Dollar AmountRow2: |
| Name Tel Email of BusinessGovt Agency InvolvedRow2: |
| Location of workRow2: |
| When will contract be completedRow2: |
| Contract Row3: |
| Dollar AmountRow3: |
| Name Tel Email of BusinessGovt Agency InvolvedRow3: |
| Location of workRow3: |
| When will contract be completedRow3: |
| 13a CERTIFYING OFFICIALS NAME AND TITLE: |
| 13b SIGNATURE: |
| 14 DATE: |
| Text1: |
| Text2: |
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| Check Box10: Off |
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| Check Box13: Off |
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