C04d Experience Questionnaire _1240LT27Q0026.pdf

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 Telephone Number, SAM UEI

2. Submitted to (Office Name and Address) 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 roofing and/or the reroofing 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:

o Tell how you removed and properly disposed of roofing systems similar to that listed in the SOW.

o Tell how you installed roofing systems similar to that listed in the SOW.

o Tell how you have worked with metal fabrication for roofing requirements similar to that listed in the SOW.

o Explain your Ability to meet past project requirements according to provided specifications.

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

6.F

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:

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

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:

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.

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