Attachment_5-_Past_Performance_Data_Document.docx

PAST EXPERIENCE & REFERENCES QUESTIONNAIRE

**ALL INFORMATION MUST BE PROVIDED TO BE COMPLIANT WITH SOLICITATION**

Your Company Name:

SAM Unique Entity ID (UEI)#:

Street Address:

City, State and ZIP Code:

POC Name:

POC Phone Number:

POC Email:

Type of Business: Corporation Partnership Sole Proprietor Other (describe)

To receive consideration, complete and submit the information requested below with your proposal. If additional space is needed this form may be duplicated as necessary or you can provide your own form.

1) How many years’ experience does your business have in services? .

2) How many years’ experience in contracting has your business had as a Prime Contractor , or a Sub- contractor . How many of these years were performed for Federal Government Contracts .

3) Have you ever Failed to Complete any work awarded to you? Yes or No. If “yes” specify reasons why.

Past Experience Questionnaire – 140F0922Q0105 Page 1 of 2

4) Key Personnel Available for this Project:

a) Minimum # of Employees:

Maximum # of Employees:

b) Are employees regularly on your payroll? Yes or No

c) How many employee(s) do you anticipate to perform the work contemplated by this solicitation?

d) Are you a sole proprietor? Yes or No

e) If you are a Prime Contractor hiring a Sub Contractor, provide the name and location of the Sub Contractor: .

5) Employee Experience: Provide the below information for each employee(s) who will perform the work contemplated by this solicitation:

Present Position/Title: Years of Experience:

6) References and Relevant Past Performance/Experience:

Experience must have been completed within the past three (3) years and be similar in size and complexity to those stated in the Scope of Work. Government contracts are preferred; but, if you have not performed Government contracts, indicate any other contracts completed or in progress.

First Contract Reference:

Contract Agency or Company Name:

Contract Number (if applicable):

Total Contract $ Value:

Point of Contact (POC) Name:

POC Telephone #:

POC E-mail address:

Contract Start and End Date:

Scope of Project: (Sufficient detailed information must be provided for the Government to perform an evaluation)

Second Contract Reference:

Contract Agency or Company Name:

Contract Number (if applicable):

Total Contract $ Value:

Point of Contact (POC) Name:

POC Telephone #:

POC E-mail address:

Contract Start and End Date:

Scope of Project: (Sufficient detailed information must be provided for the Government to perform an evaluation)

Third Contract Reference:

Contract Agency or Company Name:

Contract Number (if applicable):

Total Contract $ Value:

Point of Contact (POC) Name:

POC Telephone #:

POC E-mail address:

Contract Start and End Date:

Scope of Project: (Sufficient detailed information must be provided for the Government to perform an evaluation)

7) 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 Government with any information needed to verify my business and employee’s capability to perform this project.

Certifying Official’s Name and Title: Date: