Attachment_3_Past_Performance_Survey.pdf
PDF 154 KB Posted
- Attached to
- Relocation Assist Service at Middlesex County CT Federal contract opportunity
- Solicitation number
- 140FS325Q0036
About this file
This is a Past Performance Survey template form used to gather information about a contractor's previous contract experience. The 5-page form requires contractors to provide details about their company (including UEI number and small business status) and information about three previous contracts or subcontracts, preferably government contracts. For each contract, contractors must provide details including the contracting agency, point of contact, contract number, dollar amount, project scope, role (prime/joint venture/subcontractor), period of performance, completion dates, quality control and safety plans, and any problems encountered and their resolutions.
The form is related to a Department of Interior Fish and Wildlife Service solicitation (#140FS325Q0036) for Relocation Assistance Services in Middlesex County, CT. However, the template itself is a standard past performance information collection form and does not contain any specific requirements or details about the relocation assistance services being solicited.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Sol_140FS325Q0036.pdf | ||
| Attachment_2_Wage_Determination.pdf | ||
| Attachment_1_SOW_Relocation_Assistance_Haddam.docx | DOCX document |
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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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