Attch4_Questionnaire_2pp-fillable.pdf

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

140FGA26Q0074 Flooring Replacement