Attachment 9 Specialized Experience Form.docx
DOCX document 19 KB Posted
- Attached to
- Kayenta Staff Quarters Abatement and Demolition
- Solicitation number
- 75H70123R00063
About this file
This document is a specialized experience form for solicitation number 75H70123R00063 to provide abatement and demolition services for the Kayenta Staff Quarters. Companies are required to submit details on at least two but no more than four relevant past projects completed within the last six years, including project name and number, prime contractor or subcontractor status, construction dates and value, location, completion date, scope of work performed, and references. Eligible small businesses include Native American-owned, 8(a), HUBZone, SDVOSB, WOSB, and small business entities. The contracting agency is the Department of Health and Human Services Indian Health Service.
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Text version
Solicitation Number: 75H70123R00063 Attachment 9
SPECIALIZED EXPERIENCE FORM
75H70123R00063 KAYENTA STAFF QUARTERS ABATEMENT AND DEMOLITION
COMPANY INFORMATION
Company Name
Physical Address
SAM UEI Number
POINT OF CONTACT
Contact Name
Phone Number
Email Address
TYPE OF BUSINESS
Native American-owned (IEE/ISBEE), SBA certified 8(a), SBA Certified HUB Zone, Service Disabled Veteran-Owned Small Businesses (SDVOSB), Women Owned Small Business (WOSB), and/or Small Businesses (SB). For more information refer to http://www.sba.gov. IEE firms must submit Attachment 1: IHS IEE Representation Form (Jan 2022) along with the controlling enterprise’s Tribal enrollment/certificate of Degree of Indian Blood documentation
Type of Business?
COMPANY DESCRIPTION AND CORE CAPABILITIES
Summary description of the company, major services offered, and core capabilities related to the SOW of this project.
EXPERIENCE SUBMISSION
Requirements: Submit at least two (2) but no more than four (4) projects completed by your firm within the last six (6) years that are similar to the work that will be required under this project.
PROJECT 1
Project Name and Number
Prime or Subcontractor?
Dates of Construction
Contract Value
Contract Location
Contract Completion Date
Description of Scope Performed and Complexity (expand as needed)
Federal, State, Tribal, or Other?
Project Reference(s)/Agency Point of Contact (Title, Name, Phone, Email)
PROJECT 2
Project Name and Number
Prime or Subcontractor?
Dates of Construction
Contract Value
Contract Location
Contract Completion Date
Description of Scope Performed and Complexity (expand as needed)
PROJECT 3
Project Name and Number
Prime or Subcontractor?
Dates of Construction
Contract Value
Contract Location
Contract Completion Date
Description of Scope Performed and Complexity (expand as needed)
Federal, State, Tribal, or Other?
Project Reference(s)/Agency Point of Contact (Title, Name, Phone, Email)
PROJECT 4
Project Name and Number
Prime or Subcontractor?
Dates of Construction
Contract Value
Contract Location
Contract Completion Date
Description of Scope Performed and Complexity (expand as needed)
Federal, State, Tribal, or Other?
Project Reference(s)/Agency Point of Contact (Title, Name, Phone, Email)
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