Attachment 4 Past Performance Questionaire (Site Prep 2024 Contract).docx

12444124R0014 SRS Herbicide Site Prep

PAST PERFORMANCE / EXPERIENCE QUESTIONNAIRE (Offeror fills out this form) Instructions: See Box 9, remarks, if extra space is needed to answer any item below. Additional sheets may be attached.

1. Contractors Name, Address, Telephone Number, and point of contact

2. Type of Business __Company __Co-Partner __Corporation __Individual __Non-profit

3. Describe your standard handling procedures in safe guarding chemicals during spraying operations.

4. How many years experience do you have in this line of work____Yrs

5. How many years experience as a prime contractor_____ subcontractor___

6. LIST OF PROJECTS YOUR BUSINESS HAS COMPLETED WITHIN THE LAST 3 YEARS

NOTE: The description of work performed should be in sufficient detail for the Government to determine what the work included (i.e. what tasks were performed such as grounds maintenance, erosion control, mulching, forestry work performed, type of equipment used, special safety or requirements; include acres for each contract). Use of only a project title does not usually provide enough detail for the Government to make an evaluation.

Contract Number:______________________________________ Award Amount: _________________________________ Client/Company’s Name/Address: ________________________________________________________________________ Contact Name and Telephone number: ____________________________________________________________________ Description of Work Performed and Acres:__________________________________________________________________ Date completed or scheduled for completion: ______________________________________________________________

Contract Number:______________________________________ Award Amount: _________________________________ Client/Company’s Name/Address: ________________________________________________________________________ Contact Name and Telephone number: ____________________________________________________________________ Description of Work Performed and Acres:_________________________________________________________________ Date completed or scheduled for completion: ______________________________________________________________

Contract Number:______________________________________ Award Amount: _________________________________ Client/Company’s Name/Address: ________________________________________________________________________ Contact Name and Telephone number: ____________________________________________________________________ Description of Work Performed and Acres:_________________________________________________________________

Date completed or scheduled for completion: ______________________________________________________________

Contract Number:______________________________________ Award Amount: _________________________________ Client/Company’s Name/Address: ________________________________________________________________________ Contact Name and Telephone number: ____________________________________________________________________ Description of Work Performed and Acres: __________________________________________________________________

Date completed or scheduled for completion: ______________________________________________________________

Contract Number:______________________________________ Award Amount: _________________________________ Client/Company’s Name/Address: ________________________________________________________________________ Contact Name and Telephone number: ____________________________________________________________________ Description of Work Performed and Acres:_________________________________________________________________ Date completed or scheduled for completion: ______________________________________________________________

6a. Have you ever failed to complete any work awarded to you? __yes __ no

6b. Has work ever been completed by performance bond? __yes __ no

6c. If "yes" to either item 7a or 7b specify location(s) and reason(s) why

7. List the experience of the principal individuals of your business (Workforce composition that will be used for this project):

8. NAME AND COMMERCIAL APPLICATOR’S LICENSE #:

CATEGORY #:

STATE:

EXPIRATION DATE:

9. REMARKS (Additional sheets may be attached to the Past Performance / Experience questionnaire)

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 Forest Service with any information needed to verify my capability to perform this project:

Name:

Signature:

PAST PERFORMANCE QUESTIONNAIRE (Offeror’s clients fill out Section B of this form)

SECTION A: CONTRACTOR INFORMATION

A. Contractor’s Name and Address: _________________________________________________________

B. Point of Contact: _____________________________________________________________________

C. Phone #: ______________________________________________________________________________

D. Contract Number: ___________________________ Contract Type: _______________________________

E. Project Title: _______________________________________________________________________

F. Period of Performance: ___________________________________________________________________

G. Brief Description/Scope of Services provided: ________________________________________________

H. Authorization is hereby granted to provide the information requested in SECTION B of this questionnaire.

Signature of Offeror Date

Printed Name and Title of Offeror

SECTION B (RESPONDENT INFORMATION):

A. Name:_____________________________________________________________________________

B. Position:___________________________________________________________________________

C. Telephone Number:____________________________________ Fax Number: ___________________

D. Email Address:

E. Physical Address:____________________________________________________________________

F. Relationship and Time Involved with Contractor: ___________________________________________

G. Signature and Date Questionnaire Completed: ______________________________________________

Circle the ratings (Including Yes and No):

E

CONTRACT PERFORMANCE

No

N/A

No

N/A

No

N/A

No

N/A

No

N/A

QUALITY OF SERVICE/CONTROL

No

N/A

TIMELINESS OF PERFORMANCE

No

N/A

No

N/A

SAFETY

No

N/A

REMARKS: If additional remarks are necessary, please attach an additional sheet.