Attch3_Questionnaire_2pp-fillable_v2.pdf
PDF 220 KB Posted
- Attached to
- SD-DC BOOTH HNFH-REPLACE FIRE ALARM PANEL Federal contract opportunity
- Solicitation number
- 140FGA26Q0014
About this file
This is a Technical Experience & References Questionnaire form for the D.C. Booth NFH Replace Fire Alarm System Panel & Components solicitation (140FGA26Q0014) issued by the US Fish and Wildlife Service. The form is designed to be completed by contractors submitting quotes and may be filled out manually or using Adobe, with provisions for duplicating the form or providing an alternative format if additional space is needed.
The questionnaire requires contractors to provide: their name, address, email, telephone number, and SAM UEI number; identification of business type (corporation, non-profit organization, partnership, sole proprietor, or other); years of experience in the line of work and as a prime contractor; disclosure of any failures to complete awarded work; and three contract references completed within the past three years that are similar in size and complexity to the stated scope of work, with government contracts preferred. For each reference, contractors must supply the contract agency or company name, contract number, total contract value, point of contact information including name, telephone, and email address, contract dates, and a detailed project scope description. The form also requires listing principal individuals assigned to the project with their present positions, years of experience, and type of work performed. A remarks section is available for additional information, and the form concludes with a certification statement that the contractor intends to complete the project as specified, that all statements are complete and correct, and that named references are authorized to provide verification information to the US Fish and Wildlife Service.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Attch2_B03_SCA-WD-SD2015-5377_8pp.pdf | ||
| Attch1_SOW_BoothHouse_ReplaceFireAlarmSyst_260318_7pp_Redacted.pdf | ||
| Sol_140FGA26Q0014.pdf | ||
| B08_140FGA26Q0014_TermsConditions_37pp.pdf |
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Text version
TECHNICAL EXPERIENCE & REFERENCES QUESTIONNAIRE
Attachment
Instructions: This form may be completed manually or by using Adobe. See Box 9 “Remarks” if extra space is needed to answer an item below. Mark “x” in the appropriate boxes.
1. Contractor’s Name, Address & Telephone No.:
Name:
Address:
Email Address:
Telephone No.:
SAM UEI No.:
2. Type of Business
Corporation Non-Profit Org Partnership Sole Proprietor Other (describe)
To receive consideration, complete and submit the information requested below with your quote. If additional space is needed, this form may be duplicated as necessary or you can provide your own form.
3. How many years’ experience does your business have in this line of work? Years
4. How many years’ experience as a prime contractor? Years
5. Have you ever Failed to Complete any work awarded to you? Yes No If “yes”, specify the reasons why.
6. References and Relevant Past Performance/Experience:
Experience must have been completed within the past three (3) years and be similar in size and complexity to those stated in the Scope of Work. Government contracts are preferred, but if you have not performed Government contracts, indicate any other contracts completed or in progress.
a. First Contract Reference:
Contract Agency or Company Name Contract Number (if applicable) Total Contract $ Value Point of Contact (POC) Name POC Telephone Number POC E-mail address Contract Start and End Date Scope of Project: Provide sufficient detail for the Government to perform an evaluation)
Attachment
b. Second Contract Reference:
Contract Agency or Company Name Contract Number (if applicable) Total Contract $ Value Point of Contact (POC) Name POC Telephone Number POC E-mail address
c. Third Contract Reference:
Contract Agency or Company Name Contract Number (if applicable) Total Contract $ Value Point of Contact (POC) Name POC Telephone Number POC E-mail address
7. List the experience of principal individuals with proper qualifications/certifications to be used on this project:
Individual’s Name Present Position Years Experience Type of Work
8. Remarks:
CERTIFICATION: I certify that I intend to complete the project as specified and that my offer conforms to the specifications of the solicitation without deviation unless I provide an alternate proposal. All 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 US Fish and Wildlife Service with any information needed to verify my capability to perform this project.
Signature Title Date
| Name: |
| Address: |
| AddressRow1: |
| AddressRow2: |
| Email Address: |
| Telephone No: |
| SAM EUI No: |
| Contract Agency or Company Name: |
| Contract Number if applicable: |
| Total Contract Value: |
| Point of Contact POC Name: |
| POC Telephone Number: |
| POC Email address: |
| Contract Start and End Date: |
| Scope of Project Provide sufficient detail for the Government to perform an evaluation: |
| Contract Agency or Company Name_2: |
| Contract Number if applicable_2: |
| Total Contract Value_2: |
| Point of Contact POC Name_2: |
| POC Telephone Number_2: |
| POC Email address_2: |
| Contract Start and End Date_2: |
| Scope of Project Provide sufficient detail for the Government to perform an evaluation_2: |
| Contract Agency or Company Name_3: |
| Contract Number if applicable_3: |
| Total Contract Value_3: |
| Point of Contact POC Name_3: |
| POC Telephone Number_3: |
| POC Email address_3: |
| Contract Start and End Date_3: |
| Scope of Project Provide sufficient detail for the Government to perform an evaluation_3: |
| Individuals NameRow1: |
| Present PositionRow1: |
| Years ExperienceRow1: |
| Type of WorkRow1: |
| Individuals NameRow2: |
| Present PositionRow2: |
| Years ExperienceRow2: |
| Type of WorkRow2: |
| Individuals NameRow3: |
| Present PositionRow3: |
| Years ExperienceRow3: |
| Type of WorkRow3: |
| Title: |
| Check Box1: Off |
| Check Box2: Off |
| Check Box3: Off |
| Check Box4: Off |
| Check Box5: Off |
| Text6: Other (if applicable): |
| Text7: |
| Text8: |
| Check Box9: Off |
| Check Box10: Off |
| Solicitation: Project: D.C. Booth NFH Replace Fire Alarm System Panel & Components |
Solicitation Number: 140FGA26Q0014
| Remarks: |
| Date14_af_date: |
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