Attachment 5 - Experience Questionnaire.pdf

Attachment 5 -1243ZP20Q0024 Fire Detection and Notification Alarm System Installation Page 1 of 2

EXPERIENCE QUESTIONNAIRE

Instructions: See Box 8, remarks, if extra space is needed to answer any items below. Additional sheets may be attached.

1. Contractors Name, Address & Telephone No. 2. Type of Business __ Company __ Co-Partner __ Non-profit

__ Corporation __ Individual

3. How many years’ experience do you have in this line of work ___ Yrs

4. How many years’ experience as a prime contractor ___ subcontractor ___

5. 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. Installation of Fire Alarm Systems. List the services performed and quantities involved (Unit/Each) and any other types of services or other similar work accomplished).

Use of only a project title does not usually provide enough detail for the Government to make an evaluation.

Project Location: ________________________________________________________________________

Contract Number: _________________________ Award Amount: $________________

Period of Performance and/or Completion Date: __________________________________

Client/Company’s Name/Address: __________________________________________________________

Contact Name, Email and Telephone Number: ________________________________________________

Description of Services (Refer to Note in No. 5): _______________________________________________

Project Location: _________________________________________________________________________

Contract Number: _________________________ Award Amount: $___________________

Period of Performance and/or Completion Date: _____________________________________________

Client/Company’s Name/Address: __________________________________________________________

Contact Name, Email and Telephone Number: _______________________________________

Description of Services (Refer to Note in No. 5): _______________________________________________

Attachment 5 -1243ZP20Q0024 Fire Detection and Notification Alarm System Installation Page 2 of 2

Project Location: ________________________________________________________________

Contract Number: _________________________ Award Amount: $___________________

Period of Performance and/or Completion Date: ______________________________________

Client/Company’s Name/Address: _________________________________________________

Contact Name, Email and Telephone Number: _______________________________________

Description of Services (Refer to Note in No. 5): ______________________________________ 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 6a or 6b specify location(s) and reason(s) why

7. Information required to complete a responsibility determination. If necessary of the apparent successful offeror. (Additional information may be requested once a contractor is selected for award.

Moreover, contractor might need to provide additional authorization from a creditor to grant access.)

a. Credit References.

Company Name/Address Point of Contact Telephone Number Materials/Services

Provided

b. Banking Information.

Name/Address Point of Contact Telephone Number Account Number

8. REMARKS (Additional sheets may be attached to the experience questionnaire)

CERTIFCATION: 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 information needed to verify my capability to perform this project.

Name: Title: Date: