Attch5_RelevantExperienceSurvey_4pp.docx
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- Attached to
- CO-ROCKY MTN ARSNL NWR-PATCH HILL ROAD
- Solicitation number
- 140FGA26Q0059
About this file
This is a Past or Present Relevant Experience Survey form designed to collect information about a prospective contractor's qualifications and performance history for federal contract consideration. The form requests general business information including company name, address, establishment date, corporate structure, and SAM.gov Unique Entity ID. Respondents must provide detailed information on up to three completed or in-progress contracts or subcontracts, whether from government or commercial sources, including the contracting agency or company, project title and location, contract number, contract amount, period of performance, completion dates, and the respondent's role as prime contractor, joint venture partner, or subcontractor.
For each contract listed, the form requires disclosure of work subcontracted to others with associated amounts, percentage of work completed, termination status, and documentation of quality control and safety plans implemented. Respondents must describe any quality control or safety problems encountered and explain their resolution. The form concludes with certification requirements and requests contact information and signature from the survey preparer. This template is a standard evaluation tool used in federal procurement to assess contractor past performance and experience relevant to the solicitation for the Rocky Mountain Arsenal National Wildlife Refuge asphalt surface repair project (Solicitation Number 140FGA26Q0059) issued by the Department of the Interior Fish and Wildlife Service.
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Text version
PAST OR PRESENT RELEVANT EXPERIENCE
Your Company Name:
Street Address:
City, State and ZIP Code:
1. GENERAL BUSINESS INFORMATION
Date Firm Organized/Established:
| Company President: | Vice President: | |
| SAM.gov Unique Entity ID: | ___________________ |
Is company a ; Partnership [ ] Separate entity [ ] Division [ ] N/A [ ]
2. CONTRACTS/SUBCONTRACTS COMPLETED OR IN PROGRESS
Complete and submit the information requested below on prime contracts or subcontracts completed or in progress. Government contracts are preferred; but, if you have not performed Government contracts, indicate any other contracts completed or in progress.
a. First Contract:
Contracting Agency or Company:
| Point of Contact: | Telephone Number: | ||
| Contract Number: | Contract/Subcontract Amount: $ | _____ |
Project Title and Location:
General Scope of Project: ____________
Your Role (Prime [ ], Joint Venture [ ], or Subcontractor [ ]) and the work your firm performed:
Describe any Work You Subcontracted to Others:
Total Amount of Subcontract(s): $ Period of Performance: days Scheduled Completion Date:
Actual Completion Date: Percentage of Work Completed: % Were You Terminated?
Did you use a Quality Control Plan? _________ Did you use a Safety Plan?_______________
Quality Control or Safety Problems encountered (if any):
How were the problems resolved? _____
b. Second Contract:
Contracting Agency or Company:
| Point of Contact: | Telephone Number: | ||
| Contract Number: | Contract/Subcontract Amount: $ | _____ |
Project Title and Location:
General Scope of Project: ____________
Your Role (Prime [ ], Joint Venture [ ], or Subcontractor [ ]) and the work your firm performed:
Describe any Work You Subcontracted to Others:
Total Amount of Subcontract(s): $
Scheduled Completion Date:
Actual Completion Date: Percentage of Work Completed: % Were You Terminated?
Quality Control or Safety Problems encountered (if any):
How were the problems resolved? _____
c. Third Contract:
Contracting Agency or Company:
| Point of Contact: | Telephone Number: | ||
| Contract Number: | Contract/Subcontract Amount: $ | _____ |
Project Title and Location:
General Scope of Project: ____________
Your Role (Prime [ ], Joint Venture [ ], or Subcontractor [ ]) and the work your firm performed:
Describe any Work You Subcontracted to Others:
Total Amount of Subcontract(s): $
Scheduled Completion Date:
Actual Completion Date: Percentage of Work Completed: % Were You Terminated?
Quality Control or Safety Problems encountered (if any):
How were the problems resolved? _____
Type or Print Information Name of Survey Preparer
Phone:_________________ E-Mail;___________________________ Title Signature Date )4. Certification of Past Performance Information:
File details come from the government source that posted it. Updated .