Attachment 5.pdf
PDF 36 KB Posted
- Attached to
- Monongahela National Forest Tree Planting IDIQ Federal contract opportunity
- Solicitation number
- 12444323R0005
- Issued by
- Department of Agriculture Forest Service
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 12444323R0005.pdf | ||
| Attachment 1_SOW.pdf | ||
| Attachment 3_Map.pdf | ||
| Attachment 2_Proper Planting.pdf | ||
| Attachment 4 _Wage Determination.pdf |
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Text version
CONTRACTOR’S QUALIFICATIONS AND PAST PERFORMANCE
SECTION 1 – GENERAL INFORMATION
1A.NAME 2. TYPE OF ORGANIZATION (CHECK ONE)
A. Sole Proprietorship F. LLC
1B. STREET ADDRESS B. General Partnership
G. Joint Venture
C. Limited Partnership
H. Non-Profit/Education
1C. CITY 1D. STATE 1E. ZIP/POSTAL D. Corporation i. Other: Specify E. Subchapter S.
3. EMAIL ADDRESS:
6. DUNS NUMBER 7. TAXPAYER ID NUMBER :
8. KIND OF PRODUCT OR SERVICE PROVIDED:
10. KIND OF BUSINESS- Specify one block (plus “J” if applicable)
A. LARGE BUSINESS E. WOMAN OWNED SDB I. INDIAN SDB
B. SMALL BUSINESS F. VETERN SMALL BUSINESS J. HUB ZONE - Also C. SMALL DISADVANTAGED BUSINESS G. VETERAN SDB K. Other: Please Specify
D. WOMAN OWNED SMALL BUSINESS H. INDIAN SMALL BUSINESS
11. OWNERSHIP INFORMATION – PARTNERS – PRINCIPALS - OTHERS
NAME TITLE
13.
14.
15.
16. Questions. If “Yes” to any below, provide detailed information in section vii, remarks. Yes No A. Have you/your affiliates ever filed for bankruptcy?
B. Do you have any judgments, liens, pending suits?
C. Do you have any contingent liabilities?
D. Have you/your affiliates discontinued business operations with outstanding debts
SECTION II. GOVERNMENT FINANCIAL AID AND INDEBTNESS
If “Yes” provide detailed information in Section VII, remarks.
Yes No
17. Are you delinquent on any Federal Debt (OMB Circular 129)
18. Do you owe the Government for any contract or other claims?
19. Are you currently receiving Government Financing? (Bonds, Loans, Advanced Payments, Progress Payments, Other)
19a. Are you now in or pending Default on ANY Obligations (i.e. Banks, Financial Institutions, Suppliers, Other)?
IF yes please provide detailed information in Section VII remarks.
SECTION III – REFERENCES– CURRENT CONTRACTS INFORMATION (Optional)
20. CONTRACT 1 21. CONTRACT 2
LOCATION LOCATION
OWNERS NAME OWNERS NAME
CONTACT PERSON CONTACT PERSON
TELEPHONE TELEPHONE
FAX FAX
ADDRESS (City, State, Zip/Postal) ADDRESS (City, State, Zip/Postal)
TYPE OF WORK TYPE OF WORK
CONTRACT AMOUNT CONTRACT AMOUNT
% COMPLETE % COMPLETE
ESTIMATED COMPLETION DATE ESTIMATED COMPLETION DATE
22. CONTRACT 3 23. CONTRACT 4
LOCATION LOCATION
OWNERS NAME OWNERS NAME
CONTACT PERSON CONTACT PERSON
TELEPHONE TELEPHONE
FAX FAX
ADDRESS (City, State, Zip/Postal) ADDRESS (City, State, Zip/Postal)
TYPE OF WORK TYPE OF WORK
CONTRACT AMOUNT CONTRACT AMOUNT
% COMPLETE % COMPLETE
ESTIMATED COMPLETION DATE ESTIMATED COMPLETION DATE
SECTION V – REMARKS
REMARKS – Cite those sections of the form relating to your remarks. If additional space is needed, please use blank pages and appropriately identify them as section vii and refer to cited sections.
CERTIFICATION
By signing the Offer and completing this format, this form becomes part of the Business Proposal offer. The Government’s purpose for requesting this information is to establish offeror’s financial responsibility, considered other than certified cost and pricing data to assist the Government in determining fair, reasonable, and realistic prices, past performance acceptability, and the offeror’s responsibility. The information requested on this document is not to be considered Certified Cost and Pricing Data. All information shall be considered true and correct as of the date of form completion or date of signature on the offer. All such certifications are subject to the general certifications stated in Section K representations and certifications of the RFP.
SECTION IV – REFERENCES - PAST PERFORMANCE – COMPLETED CONTRACTS INFORMATION (Optional)
24. CONTRACT 1 25. CONTRACT 2
LOCATION LOCATION
OWNERS NAME OWNERS NAME
CONTACT PERSON CONTACT PERSON
TELEPHONE TELEPHONE
FAX FAX
ADDRESS (City, State, Zip/Postal) ADDRESS (City, State, Zip/Postal)
TYPE OF WORK TYPE OF WORK
CONTRACT AMOUNT CONTRACT AMOUNT
% COMPLETE % COMPLETE
ESTIMATED COMPLETION DATE ESTIMATED COMPLETION DATE
26. CONTRACT 1 27. CONTRACT 2
LOCATION LOCATION
OWNERS NAME OWNERS NAME
CONTACT PERSON CONTACT PERSON
TELEPHONE TELEPHONE
FAX FAX
ADDRESS (City, State, Zip/Postal) ADDRESS (City, State, Zip/Postal)
TYPE OF WORK TYPE OF WORK
CONTRACT AMOUNT CONTRACT AMOUNT
% COMPLETE % COMPLETE
ESTIMATED COMPLETION DATE ESTIMATED COMPLETION DATE
CONTRACTOR’S QUALIFICATIONS AND PAST PERFORMANCE
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