Attch4_Questionnaire_2pp-fillable.pdf
PDF 194 KB Posted
- Attached to
- SD-LAKE ANDES NWR-REPL QUARTERS FLOORING
- Solicitation number
- 140FGA25Q0020
About this file
This document is a Past Experience & References Questionnaire for a federal construction contract with the US Fish and Wildlife Service at the Lake Andes National Wildlife Refuge in South Dakota. The two-page form requires potential contractors to provide detailed information about their business, including years of experience, business type, past contract performance, and key personnel qualifications. The questionnaire seeks three contract references from the past three years that are similar in size and complexity to the current project, which involves demolition and installation of approximately 1,722 sq ft of new flooring.
The form requires contractors to certify the accuracy of their submitted information and includes sections for documenting business details, contract experience, principal individual qualifications, and a certification statement. Contractors must disclose whether they have failed to complete any previously awarded work and provide comprehensive contact information for references that can verify their capability to perform the project. The document is part of Solicitation Number 140FGA25Q0020 and is designed to help the US Fish and Wildlife Service evaluate potential contractors' experience and competence for the flooring replacement project.
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Other files
| File | Type | Posted |
|---|---|---|
| Sol_140FGA25Q0020_Amd_0002.pdf | ||
| Sol_140FGA25Q0020_Amd_0001.pdf | ||
| Sol_140FGA25Q0020.pdf | ||
| Attch2_WD_SD20250003_5pp.pdf | ||
| Attch3_BidSchedule_1p.docx | DOCX document | |
| Attch1_SOW_250422.pdf |
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Text version
PAST EXPERIENCE & REFERENCES QUESTIONNAIRE
Instructions: This form may be completed manually or by using Adobe. See Box X, 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 EUI 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)
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
Contract Start and End Date
Scope of Project: Provide sufficient detail for the Government to perform an evaluation)
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
Contract Start and End Date
Scope of Project: Provide sufficient detail for the Government to perform an evaluation)
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: |
| Date: |
| Type of Business Describe: |
| Check Box1: Off |
| Check Box3: Off |
| Check Box2: Off |
| Check Box4: Off |
| Check Box5: Off |
| Yrs Experience: |
| Yrs Exp Prime: |
| Check Box8: Off |
| Check Box9: Off |
| Remarks: |
| Text1: USFWS SD - Lake Andes NWR |
New Flooring for Government Housing Quarters
File details come from the government source that posted it. Updated .