Attachment_3_-_Past_Performance_Reference_List.docx

Past Performance Questionnaire

(THIS MUST BE COMPLETED AND SUBMITTED WITH YOUR QUOTE)

Contractor Name:______________________________________________________________________

Address:__________________________________ City:_______________ State: _____ Zip:________

Phone Number: ____________________ SAM Entity Number (UEI): ____________________________

Type of Business:

_____Company ____Co-partnership ______Corp._____ Individual ____Non-Profit Org.

1. How many years of RELEVENT experience do you have and/or your company have regarding the types of work requested by this solicitation?

-You__________________ -Your Company__________________

2. How many years of experience in contracting does your company have as a Prime Contractor and/or a Sub-Contractor:

-Prime_________________ -Sub-Contractor__________________

3. List below three projects your business has completed within the last five years. Include the contract number and amount; the type of project; the date completed and a reference contact name and telephone number for each project.

Note: Past Projects must be relevant to the requirements of this solicitation in terms of duties performed, and the technical/complexity aspects of the duties required. Projects listed that are not relevant to this solicitation and its requirements will not be considered. (attach separate page if additional room is needed)

4. List all contract commitments you have that will run concurrently with the work requested in this solicitation. Include name, address, telephone number, start and finish date.

5. Have you ever failed to complete any work awarded to you? ______Yes _____No

6. Has work ever been completed by performance bond? ______Yes ______No

If “Yes” to either item, specify location and reason:

7. Response to the following questions:

O Judgments, Claims, and Lawsuits: Are there any judgments, claims, and/or lawsuits pending or outstanding against or involving entity or partners comprising your entity?

No ☐, Yes ☐. If yes, submit details of all judgments or claims against either parent office or division/branch that will be responsible for the accomplishment of this project on a separate sheet.

O Is your entity or partners comprising your entity under suspension or debarment by any Federal, state, or local agency, or been terminated on any past projects (Federal or others)?

No ☐, Yes ☐. If yes, submit details on a separate sheet.

O IAW FAR 52.209-7(b), the offeror ☐ has ☐ does not have current active Federal contracts and grants with total value greater than $10,000,000.

O IAW FAR 52.204-24(d),

(1) The offeror ☐ will, ☐ will not provide covered telecommunications equipment or services to the Government in the performance of any contract, subcontract or other contractual instrument resulting from this solicitation. The Offeror shall provide additional disclosure information IAW FAR 52.204-24(e)(1) if the Offeror responds "will".

(2) The offeror represents that it ☐ does, ☐ does not use covered telecommunications equipment or services, or use any equipment, system, or service that uses covered telecommunications equipment or services. The Offeror shall provide additional disclosure information IAW FAR 52.204-24(e)(2) if the Offeror responds "does".

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 Bureau of Land Management with any information needed to verify my capability to perform this project.

Certifying Official Name and Title :

Authorized Signature:

Date: