Attch_5_Past_Performance_Questionnaire.doc

Past Performance Questionnaire

(THIS MUST BE COMPLETED AND SUBMITTED WITH YOUR QUOTE)

Contractor Name:______________________________________________________________________ Address:__________________________________ City:_______________ State: _____ Zip:________ Phone Number: ____________________ DUNS Number: ____________________________ Type of Business:

_____Company ____Co-partnership ______Corp._____ Individual ____Non-Profit Org.

1. How many years of RELEVENT experience do you have and/or your company have regarding the types of work requested by this solicitation?

-You__________________ -Your Company__________________

2. How many years of experience in contracting does your company have as a Prime Contractor and/or a Sub-Contractor:

-Prime_________________ -Sub-Contractor__________________

3. List below projects your business has completed within the last three years. Include the contract number and amount; the type of project; the date completed and a reference contact name and telephone number for each project.

Note: Past Projects must be relevant to the requirements of this solicitation in terms of duties performed, and the technical/complexity aspects of the duties required. Projects listed that are not relevant to this solicitation and its requirements will not be considered. (attach separate page if additional room is needed)

4. List all contract commitments you have that will run concurrently with the work requested in this solicitation. Include name, address, telephone number, start and finish date.

5. Have you ever failed to complete any work awarded to you? ______Yes _____No

6. Has work ever been completed by performance bond? ______Yes ______No

If “Yes” to either item, specify location and reason:

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 Bureau of Land Management with any information needed to verify my capability to perform this project.

Certifying Official Name and Title :

Authorized Signature (Sign in Ink):

Date: