Attachment F - Past Performance Experience Questionnaire.pdf

USDA Forest Service Pacific Southwest Region

PAST PERFORMANCE

EXPERIENCE QUESTIONNAIRE

1. CONTRACTOR NAME, ADDRESS AND PHONE NUMBER

2. SUBMITTED TO (Office Name & Address) 3. BUSINESS:

__Company ___Co-partnership __Corporation ___Individual __Non-profit Organization

4. How many years do you or your firm have in the line of work contemplated by this solicitation?

5. HOW MANY YEARS EXPERIENCE IN CONTRACTING HAVE YOU OR YOUR COMPANY HAD AS A:

PRIME CONTRACTOR_________________ AND/OR SUB-CONTRACTOR_____________

6. LIST BELOW ALL PUMPING SERVICES PROJECTS YOUR BUSINESS HAS COMPLETED WITHIN THE LAST THREE YEARS:

CONTRACT

AMOUNT TYPE OF PROJECT

DATE

COMPLETED

NAME,ADDRESS, AND PHONE OF OWNER /PERSON

TO CONTACT FOR PROJECT INFORMATION

7. LIST BELOW ALL OF YOUR CONTRACTUAL COMMITMENTS RUNNING CONCURRENTLY WITH THE

WORK CONTEMPLATED BY THIS PROJECT:

CONTRACT

NUMBER

AMOUNT

OF

AWARD

NAME, ADDRESS & PHONE # OF BUSINESS/GOVERNMENT

AGENCY INVOLVED

AWARDED

(UNITS)

PERCENT

COMPLETED

DATE

COMPLETED

_____NO

_____NO

8a. HAVE YOU EVER FAILED TO COMPLETE ANY WORK AWARDED TO YOU? ______YES 8b. HAS WORK EVER BEEN COMPLETED BY PERFORMANCE BOND? ______YES 8c. IF “YES” TO EITHER ITEMS SPECIFY LOCATION(S) AND REASON(S)WHY:

EXPERIENCE QUESTIONNAIRE PAGE 2

9. ORGANIZATION AND WORKERS THAT WILL BE AVAILABLE FOR THIS PROJECT:

a. MINIMUM NUMBER OF EMPLOYEES:___________ AND MAXIMUM NUMBER OF EMPLOYEES:__________

b. ARE EMPLOYEES REGULARLY ON YOUR PAYROLL? ______YES _______ NO

c. PROVIDE LIST OF SUBCONTRACTORS, if applicable.

d. HAS YOUR COMPANY SERVICED THE GEOGRAPHIC AREA(S) CONTEMPLATED IN THIS SOLICITATION:

______ YES _____ NO

10. LIST BELOW THE EXPERIENCE OF THE PRINCIPAL INDIVIDUALS OF YOUR BUSINESS:

INDIVIDUAL’S NAME

PRESENT

POSITION

YEARS

OF EXP MAGNITUDE AND TYPE OF WORK

11. REMARKS: SPECIFY BOX NUMBERS (Attach sheets if extra space is needed to fully answer any of the above questions):

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.

12a. CERTIFYING OFFICIAL’S NAME AND TITLE

12b. SIGNATURE 13.

DATE