Attachment 6-Relevant Experience-Past Performance Questionnaire.doc
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- Solicitation number
- 12441923Q0095
- Issued by
-
Department of Agriculture Forest Service
About this file
This document is a past performance questionnaire for contractors responding to solicitation number 12441923Q0095 for the Midewin National Tallgrass Prairie Group 65 and Group 66 Bunker Demolition blanket purchase agreement. The Forest Service is seeking contractors with experience in grounds maintenance, erosion control, mulching, forestry work, and demolition using various equipment. Respondents must provide details on at least five relevant projects from the past three to five years, including contract numbers, award amounts, client names and contact information, descriptions of work performed, and completion dates. Additional questions address business experience, principal staff experience, credit and banking references, and any past failures to complete work or need for performance bonds. Certification is required from an authorized company representative.
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Text version
AG-4670-S-16-0117
ATTACHMENT 5
RELATIVE EXPERIENCE QUESTIONNAIRE
12441923Q0095
ATTACHMENT 6
RELEVANT EXPERIENCE-PAST PERFORMANCE QUESTIONNAIRE
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 No., & Email
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 RELEVANT PROJECTS YOUR BUSINESS HAS COMPLETED WITHIN THE LAST THREE (5) 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, (grounds maintenance, erosion control, mulching, forestry work performed, type of equipment used, special safety or requirements) 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: _________________________________________________________________________
Date completed or scheduled for completion: ______________________________________________________________
Contract Number:______________________________________ Award Amount: _________________________________ Client/Company’s Name/Address: ________________________________________________________________________
Contact Name and Telephone number: ____________________________________________________________________ Description of Work Performed: _________________________________________________________________________
Date completed or scheduled for completion: ______________________________________________________________
Contract Number:______________________________________ Award Amount: _________________________________ Client/Company’s Name/Address: ________________________________________________________________________
Contact Name and Telephone number: ____________________________________________________________________ Description of Work Performed: _________________________________________________________________________
Date completed or scheduled for completion: ______________________________________________________________
Contract Number:______________________________________ Award Amount: _________________________________ Client/Company’s Name/Address: ________________________________________________________________________
Contact Name and Telephone number: ____________________________________________________________________ Description of Work Performed: _________________________________________________________________________
Date completed or scheduled for completion: ______________________________________________________________
Contract Number:______________________________________ Award Amount: _________________________________ Client/Company’s Name/Address: ________________________________________________________________________
Contact Name and Telephone number: ____________________________________________________________________ Description of Work Performed: _________________________________________________________________________
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
6. If "yes" to either item 6a or 6b specify location(s) and reason(s) why
7. List the experience of the principal individuals of your business
| INDIVIDUALS NAME |
| PRESENT POSITION |
| YRS EXP |
| TYPE OF WORK |
8. Information required to complete a responsibility determination of the apparent successful offeror. (Additional information may be requested once a contractor is selected for award.. Moreover, the 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. (NOTE: Only POC information is required. Please do NOT provide your account information.)
| Company Name/Address |
| Point of Contact |
| Telephone number |
9. REMARKS (Additional sheets may be attached to the 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:
| Title: |
| Date: |
File details come from the government source that posted it. Updated .