Attachment_4__PAST_AND_PRESENT_PERFORMANCE_SURVEY.doc

ATTACHMENT 4

140F0221R0028 page 1 of 4

PAST AND PRESENT PERFORMANCE SURVEY

Your Company Name:

Street Address:

City, State and ZIP Code:

1. GENERAL BUSINESS INFORMATION

Date Firm Organized/Established:

Company President:

Vice President:

Dun & Bradstreet Number:

Is company a ; Partnership [ ] Separate entity [ ] Division [ ] N/A [ ]

2. CONTRACT BONDING INFORMATION

Name of your bonding company intended to use:

Mailing Address:

City, State (including ZIP Code):

Point of Contact:

Telephone No.: ( )

3. CONTRACTS/SUBCONTRACTS COMPLETED OR IN PROGRESS

Complete and submit the information requested on page 2-3 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.

a. First Contract:

Contracting Agency or Company:

Telephone Number:

Contract Number:

Contract/Subcontract Amount: $

Project Title and Location:

General Scope of Construction 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?

Were You Assessed Liquidated Damages?

(If the answer to either Question is “Yes”, Explain:

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?

b. Second Contract:

Contracting Agency or Company:

Telephone Number:

Contract Number:

Contract/Subcontract Amount: $

Project Title and Location:

General Scope of Construction 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?

Were You Assessed Liquidated Damages?

(If the answer to either Question is “Yes”, Explain:

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?

4. Certification of Past and Present Performance Information:

Type or Print Information

Name of Survey Preparer_______________________________

Title__________________________________________

Signature______________________________________

Date__________________________________________