Attachment 4 - Past Performance Fill-in Sample.pdf

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Attached to
Q201--Durable Medical Equipment for VA Caribbean Healthcare System
Solicitation number
36C24821Q1156
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36C24821Q1156 0001_1.docx DOCX document
DME Combine Synopsis Solicitation Questions and Answers.docx DOCX document
Attachment 5 - LOS CERTIFICATION SOLICITATION - 36C24821Q1156.pdf PDF
36C24821Q1156_1.docx DOCX document
Attachment 2 - Statement Of Work.docx DOCX document
Attachment 3 - Evaluation Criteria.docx DOCX document
Attachment 1 - DME Combine Synopsis Solicitation.docx DOCX document

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PAST PERFORMANCE INFORMATION

OFFEROR INSTRUCTIONS: Offeror must provide three (3) Past Performance references by filling out one (1) information page per reference. Include a copy of each requested Past Performance Information page with proposal submission.

Name of Offeror being evaluated:

Company Name, address, phone number and email of Reference:

Contract Details (i.e. Contract Number / Delivery or Task Order Number, Title, Place of performance, etc.) of VA, Federal, State, Local Government or commercial customers for whom the offeror has provided services as described in this solicitation.

Briefly describe the services provided to the customer, service periods, approximate annual dollar value of the services provided, and information on problems encountered, if any, and the offeror’s corrective actions.

Provide evidence of any past adverse actions by state, local or federal regulatory agencies (such as citations, notice of violations, etc).

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