Attch D_Subcontractor Information and Consent.pdf

FOR OFFICIAL USE ONLY

Source Selection Sensitive Information—See FAR 2.101 & 3.104

Solicita tion 36C25622R0140 Construct Inpatient Dialysis-NLR

ATTACHMENT D – SUBCONTRACTOR INFORMATION AND CONSENT FORM

Subcontractor and/or Teaming Partner Consent for the Release of Past Performance Information to the Prime Contractor and Reference Information

Past performance information concerning subcontractors and teaming partners cannot be disclosed to a private party without th e subcontractor’s or teaming partner’s consent. Because a prime contractor is a private party, the Government will need that consent before disclosing subcontractor/teaming partner past and present performance information to the prime during exchanges. In an effort to assist the Government in assessing your past performance relevancy we request that the following consent form be completed by the major subcontractors/teaming partners identified in your proposal. The completed consent forms should be submitted to th e offering contractor for submission with past performance volume.

(NAME OF FIRM)

is currently planning on participating as a subcontractor and or a teaming partner with

(PRIME CONTRACTOR OR NAME OF ENTITY PROVIDING PROPOSAL)

in responding to the Request for Proposal No. 36C25622R0140 to construct inpatient dialysis at Eugene J. Towbin campus issued by the Department of Veterans Affairs NCO 16 for Central Arkansas Veteran Healthcare System (CAVHS).

We understand that the Government is placing increased emphasis on past performance in order to obtain best value in source selections. In order to facilitate the performance confidence assessment process, we are signing this consent form to allow you to discuss our past and present performance information with the prime contractor during the source selection process.

(Signature) (Title of Individual with authority to sign for and Legally bind the company)

Company Name: Telephone #

Address:

City/State/Zip Code: Date:

Reference List (required):

1. Contract No. And Title:

Describe role (Prime/Sub) and work Performed:

Reference POC Name Phone: Fax:

Email address:

2. Contract No. And Title:

Describe role (Prime/Sub) and work Performed:

Reference POC Name Phone: Fax:

Email address:

3. Contract No. And Title:

Describe role (Prime/Sub) and work Performed:

Reference POC Name Phone: Fax:

Email address: