C04 Attachment 5 - Experience Questionnaire - 1240LT26Q0080.docx
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- Solicitation number
- 1240LT26Q0080
- Issued by
-
Department of Agriculture Forest Service
About this file
This is an Experience Questionnaire form required for submission to the USDA Forest Service in response to Solicitation 1240LT26Q0080 for the Duchesne Office Mechanical Room Renovation project. The questionnaire is designed to evaluate contractor capability and experience prior to award.
The form requests comprehensive information about the contractor's qualifications, including years of experience in the line of work, prime and subcontractor history, and documentation of three completed projects within the last three years demonstrating specific expertise in plumbing, carpentry work, and laminate flooring installation. Contractors must detail concurrent contractual commitments, employee availability (minimum and maximum), equipment resources, and progress rate estimates. The questionnaire also requires disclosure of any past failures to complete awarded work, use of performance bonds, and on-site project visits. Additionally, contractors must provide detailed experience information for principal individuals who will directly oversee the contract and include any supplementary information supporting their capability to successfully complete the renovation work. The form concludes with a certification statement in which the submitting official attests to the accuracy and completeness of all provided information. Responses should be submitted to Tony Taylor at tony.taylor@usda.gov.
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Text version
USDA Forest Service
EXPERIENCE QUESTIONNAIRE
Instructions: See Box 11, Remarks, if extra space is needed to answer any item below, Mark “X: in appropriate boxes.
1. Contractor Name, Address, and Email, SAM UEI.
2. Submitted to (Office Name and Address) Tony Taylor – tony.taylor@usda.gov
| 3. Business | |
| ☐ Company | ☐ Co-partnership ☐ Corporation ☐ Individual |
☐ Non-profit Organization
4. How many years do you or your firm have in the line of work contemplated by this solicitation?
5. How many years’ experience have you or your business had as a (a) prime contractor and/or (b) sub-contractor ?
6. List below the projects that include the demolition and reconstruction of facilities similar to those listed in the SOW that your business has completed within the last three years. Highlight the following factors in the Type of Project Section:
· Show your experience and knowledge with plumbing, carpentry work, and laminate flooring installation.
| Box # |
| Contract Amount |
| Type of Project |
| Date Completed |
| Name, Address, and Telephone No. of Owner/Person to Contact for Project Information |
6. A
6. B
6. C
6. D
6. E
7. List below all of your firm’s contractual commitments running concurrently with the work contemplated by this solicitation. Explain how you have kept in contact with the entity over the contract. What were the communication methods? How did you ensure that the product is what was wanted. How was the project inspected. How have you handled disputes if any?
| Contract Number |
| Dollar Amt. of Award |
| Name, Address, and Telephone No. of Business/Government Agency Involved |
| Awarded (Units) |
| Percent Completed |
| Date Contract Complete |
8a. Have you ever failed to complete any work awarded to you? ☐ Yes ☐ No 8b. Has work ever been completed by performance bond? ☐ Yes ☐ No 8c. Did you look at the project site(s) on-the-ground? ☐ Yes ☐ No 8d. If “Yes” to either item 8a. or 8b., specify location(s) and reason(s) why:
EXPERIENCE QUESTIONNAIRE CONTINUED
9. Employees and equipment that will be available for this project:
a. (1) Minimum number of employees: and (2) Maximum number of employees:
b. Are employees regularly on your payroll: ☐ Yes ☐ No
c. Specify equipment available for this contract:
d. Estimate rate of progress below (such as 2.0 acres/man/day):
(1) Minimum progress rate: and (2) Maximum progress rate:
10. List below the experience of the principal individuals of your business: (Who will directly be involved in this contract?)
| Individual’s Name |
| Present Position |
| Years of Experience |
| Magnitude and Type of Work |
11. Remarks -- Specify Box Numbers (This box will extend as information is added to accommodate extra space.):
NOTE: PLEASE PROVIDE ANY ADDITIONAL INFORMATION THAT WILL HELP EVALUATE YOUR ABILITY TO SUCCESSFULLY COMPLETE THIS PROJECT. (Examples for elaboration of projects listed in Box 6).
CERTIFICATION
I certify that all of 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 Forest Service with any information needed to verify my capability to perform this project.
12a. CERTIFYING OFFICIAL’S NAME AND TITLE
| b. SIGNATURE (Sign in ink) |
| 13. DATE |
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