Attachment_3_Past_Performance_Survey.pdf
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- Attached to
- Relocation SVS for Great Dismal Swamp Suffolk VA
- Solicitation number
- 140FS324Q0212
About this file
This document is a Past or Present Performance Survey that requests information from companies about their previous or ongoing contracts. The survey asks for general business information, including whether the company is a small business, as well as details about up to three specific contracts or subcontracts, such as the contracting agency, contract amount, scope of work, and any quality control or safety issues encountered.
The survey is related to a federal contract opportunity from the Department of the Interior Fish and Wildlife Service for relocation services at the Great Dismal Swamp National Wildlife Refuge in Suffolk, Virginia. The solicitation number is 140FS324Q0212, and contractors must submit an RFQ (SF1449) and the completed Past Performance Survey attachment to the contracting point of contact.
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Text version
ATTACHMENT 3 page 1 of 5
PAST OR PRESENT PERFORMANCE SURVEY
Your Company Name:
Street Address:
City, State/Territory and ZIP Code:
1. GENERAL BUSINESS INFORMATION
Date Firm Organized/Established:
Company President: Vice President:
WWW.SAM.GOV UEI Number:_______________ __
Is company a small business? YES [ ] NO [ ] N/A [ ]
2. CONTRACTS/SUBCONTRACTS COMPLETED OR IN PROGRESS
Complete and submit the information requested on page 2-4 below on prime contracts or subcontracts completed or in progress. Government contracts are preferred; but, if you have not performed Government contracts, indicate any other contracts completed or in progress.
http://www.sam.gov/
ATTACHMENT 3 page 2 of 5
a. First Contract:
Contracting Agency or Company:
Point of Contact: Telephone Number:
Contract Number: Contract/Subcontract Amount: $ _____
Project Title and Location:
General Scope of Project:
Your Role (Prime [ ], Joint Venture [ ], or Subcontractor [ ]) and the work your firm performed:
Describe any Work You Subcontracted to Others:
Total Amount of Subcontract(s): $
Period of Performance: days
Scheduled Completion Date:
Actual Completion Date: Percentage of Work Completed: %
Were You Terminated?
Did you use a Quality Control Plan? _________ Did you use a Safety Plan?_______________
Quality Control or Safety Problems encountered (if any):
How were the problems resolved?
ATTACHMENT 3 page 3 of 5
b. Second Contract:
Point of Contact: Telephone Number:
Your Role (Prime [ ], Joint Venture [ ], or Subcontractor [ ]) and the work your firm performed:
Scheduled Completion Date:
Actual Completion Date: Percentage of Work Completed: %
ATTACHMENT 3 page 4 of 5
c. Third Contract:
Point of Contact: Telephone Number:
Your Role (Prime [ ], Joint Venture [ ], or Subcontractor [ ]) and the work your firm performed:
Scheduled Completion Date:
Actual Completion Date: Percentage of Work Completed: %
ATTACHMENT 3 page 5 of 5
4. Certification of Past Performance Information:
Type or Print Information
Name of Survey Preparer _______________________________
Phone:__________________________ E-Mail;___________________________
Title__________________________________________
Signature______________________________________
Date__________________________________________
| PAST OR PRESENT PERFORMANCE SURVEY |
| 1. GENERAL BUSINESS INFORMATION |
| 2. CONTRACTS/SUBCONTRACTS COMPLETED OR IN PROGRESS |
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