Attachment 5 Experience_questionaire.pdf
PDF 122 KB Posted
- Attached to
- SNOW PLOWING ON THE WASHBURN RANGER DISTRICT
- Solicitation number
- 124446Q0013
- Issued by
-
Department of Agriculture Forest Service
About this file
This is an Experience and Capability Questionnaire form (OMB Clearance Number 9000-0142) used by the Forest Service to evaluate contractor qualifications for federal contract opportunities.
The form requests comprehensive information about a prospective contractor's background, experience, and resources. Respondents must provide their business name, address, telephone number, and business type (company, corporation, non-profit organization, co-partner, or individual). The questionnaire requires documentation of years of experience in the relevant field, experience as both prime and subcontractors, and a detailed list of projects completed within the past three years, including contract amounts, project types, completion dates, and references. Additionally, contractors must disclose all current contract commitments with contract numbers, amounts, project types, estimated completion dates, and contact information. The form includes questions regarding any failures to complete awarded work and whether performance bonds have been required. Contractors must specify the organization and resources available for the project, including minimum and maximum employee levels, payroll status, applicable equipment, and estimated rates of progress. Section 9 requires listing principal individuals with their positions, years of experience, and types of work performed. The form includes a remarks section for additional information and concludes with a certification statement where the authorized representative attests to the accuracy and completeness of all provided information, acknowledging that named references are authorized to verify the contractor's capability to perform the project.
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Text version
EXPERIENCE AND CAPABILITY QUESTIONNAIRE
Instructions: See Box 10, REMARKS, if extra space is needed to answer any items below. Mark "X" in the appropriate boxes. Please list NA for inapplicable items.
1. Contractor's Name, Address & Telephone Number 2. Type of Business
____ Company
____ Corporation
____ Non-profit Organization
____ Co-partner
____ Individual
3. How many years of experience do you have in this line of work? ___________________
4. How many years of experience as a prime contractor? _________ subcontractor? ________
5. List the projects your business has completed in the last 3 years.
Contract
Amount
Type of Project Date
Completed
Name and Telephone Number to
Contact For Information
6. List all of your firm's current contract commitments.
Contract
Number
Contract
Amount
Type of Project Est. Date of
Completion
Name and Telephone Number to
Contact For Information
7a. Have you ever failed to complete any work awarded to you? ____ yes ____ no
7b. Has work ever been completed by performance bond? ____ yes ____ no
7c. If "yes" to either Question 7a. or 7b., please specify location(s) and reason(s):
EXPERIENCE AND CAPABILITY QUESTIONNAIRE -- OMB Clearance Number 9000-0142
8. Organization that will be available for this project:
a. Minimum No. of employees: _______________ Maximum No. of employees: ________________
b. Are employees regularly on your payroll? ____ yes ____ no
c. If applicable, specify equipment available for this contract:
d. If applicable, estimate rate of progress (such as 2.0 acres per day):
Minimum progress rate: __________________________ Maximum progress rate: ____________________________
9. List the experience of the principal individuals of your business.
Individual's Name Present Position Years Experience Type of Work
10. Remarks:
CERTIFICATION: I certify that all of the statements made above are complete and correct to the best of my knowledge and that ny persons named as references are authorized to furnish the Forest Service with any information needed to verify my capability to perform this project.
Signature Title Date
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