Attch4_Questionnaire_2pp-fillable.pdf
PDF 203 KB Posted
- Attached to
- UT-OURAY NWR-SEPTIC REPAIR
- Solicitation number
- 140FGA26Q0061
About this file
This is a Past Experience & References Questionnaire form for the US Fish and Wildlife Service (USFWS) Ouray National Wildlife Refuge Septic Repair RFQ 140FGA26Q0061.
The form requires contractors to provide company information including name, address, email, telephone number, and SAM EUI number, along with business type classification. Contractors must document their years of experience in the relevant line of work and as a prime contractor, and disclose any failures to complete awarded work. The core requirement is submission of three contract references from projects completed within the past three years that are similar in size and complexity to the scope of work. For each reference, contractors must provide the contracting agency or company name, contract number, total contract value, point of contact information (name, telephone, email), contract dates, and a detailed description of the project scope sufficient for government evaluation. Additionally, contractors must list principal individuals assigned to the project with their current positions, years of experience, and type of work. A remarks section allows for additional information if needed. The form concludes with a certification statement in which the contractor attests to project completion capability, conformance to solicitation specifications, accuracy of all statements, and authorization of named references to provide information to USFWS verifying project performance capability. The contractor's authorized representative must sign the form with title and date.
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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 UT - Ouray National Wildlife Refuge |
Septic Repair RFQ 140FGA26Q0061
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