Attachment Contractor info and Past Performance Information Sheet.pdf

Attachment 5 Contractor Information Sheet

SECTION 1 – GENERAL INFORMATION

1A.NAME 2. TYPE OF ORGANIZATION (CHECK ONE)

A. Sole Proprietorship F. LLC

1B. STREET ADDRESS B. General Partnership G. Joint Venture C. Limited Partnership H. Non-Profit/Education

1C. CITY 1D. STATE 1E. ZIP/POSTAL D. Corporation i. Other: Specify E. Subchapter S.

3. TAXPAYER ID NUMBER :

6. DUNS NUMBER 7. VENDOR EXPRESS NUMBER: (FS VENDORS)

8. KIND OF PRODUCT OR SERVICE PROVIDED:

10. KIND OF BUSINESS- Specify one block (plus “J” if applicable)

A. LARGE BUSINESS E. WOMAN OWNED SDB I. INDIAN SDB

B. SMALL BUSINESS F. VETERN SMALL BUSINESS J. HUB ZONE - Also C. SMALL DISADVANTAGED BUSINESS G. VETERAN SDVOSB K. Other: Please Specify

D. WOMAN OWNED SMALL BUSINESS H. INDIAN SMALL BUSINESS

11. OWNERSHIP INFORMATION – PARTNERS – PRINCIPALS - OTHERS

NAME TITLE

13.

14.

15.

16. Questions. If “Yes” to any below, provide detailed information in section vii, remarks. Yes No A. Have you/your affiliates ever filed for bankruptcy?

B. Do you have any judgments, liens, pending suits?

C. Do you have any contingent liabilities?

D. Have you/your affiliates discontinued business operations with outstanding debts

SECTION II. GOVERNMENT FINANCIAL AID AND INDEBTNESS

If “Yes” provide detailed information in Section VII, remarks.

Yes No

17. Are you delinquent on any Federal Debt (OMB Circular 129)

18. Do you owe the Government for any contract or other claims?

19. Are you currently receiving Government Financing? (Bonds, Loans, Advanced Payments, Progress Payments, Other)

19a. Are you now in or pending Default on ANY Obligations (i.e. Banks, Financial Institutions, Suppliers, Other)? IF yes please provide detailed information in Section VII remarks.

Past Performance Information Sheet

EXPERIENCE/PAST PERFORMANCE QUESTIONNAIRE

INSTRUCTIONS: If extra space is needed use the reverse. Mark “X” in appropriate boxes.

CONTRACTOR NAME, ADDRESS & TELEPHONE

How many years do you or your firm have in the line of work contemplated by this solicitation ______? How many years experience in contracting have you or your business had as a (a) prime contractor _____ and/or (b) sub-contractor _____?

List below the projects your business has completed within the last 3 years:

Contract Amount Type of Project Date Completed Name Address & Telephone No. of Person to Contact for

Project Info.

List below all of your firm’s contractual commitments running concurrently with the work contemplated by this solicitation:

Contract No. Dollar Amt.

of Award Name, Address & Phone No. of Business Govt./Agency

Awarde d (Units)

Complete d

Date Contract Completed

Have you ever failed to complete any work awarded to you? Yes ( ) No ( ) Has work ever been completed by performance bond? Yes ( ) No ( ) If “Yes” to either item above specify location(s) and reason(s) why:

Organization and work that will be available for this project:

a. Minimum number of employees: ( ) and a Maximum number of employees: ( )

b. Are employees regularly on your payroll: Yes ( ) No ( )

c. Specify equipment available for this contract:________________________________________

d. Estimate rate of progress below (such as 2.0 acres/man/day):

Minimum progress rate: __________ Maximum progress rate: _____________

List below the experience of the principal individuals of your business:

Individual’s Name Present Position Years of Experience Magnitude and Type of Work

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.

Certifying Official’s Name and Title Signature (In Ink) Date