C4d_ Attachment D Experience Questionnaire 12444626Q0061.pdf
PDF 444 KB Posted
- Attached to
- Superior NF Toilet Vault Cleaning
- Solicitation number
- 12444626Q0061
- Issued by
-
Department of Agriculture Forest Service
About this file
This document is an Experience Questionnaire form (FS-6300-27) required for federal contract opportunities with the USDA Forest Service, referenced under FSH 6309.31 and 41 USC 1. The form serves as a template for contractors to submit their qualifications and past performance information for consideration in contract awards.
The questionnaire requires contractors to provide: company information including name, address, UEI number, business structure (company, corporation, co-partnership, individual, or non-profit), and years of experience in the relevant line of work and contracting (both as prime and sub-contractors). Contractors must list all projects completed within the last three years with contract amounts, project descriptions, completion dates, and owner contact information, as well as document all concurrent contractual commitments with dollar amounts, percentage completion status, and completion dates. Additionally, the form requires disclosure of any failed work completion or performance bond completion history. Contractors must detail organizational capacity including minimum and maximum employee counts, payroll status, and estimated progress rates; provide experience summaries of principal individuals; list all equipment and vehicles with maintenance plans; describe contractor self-inspection procedures, quality control methods, safety plans, bio-based product usage, and work schedules. The form concludes with a certification section requiring the certifying official's signature, name, title, and date, confirming the accuracy and completeness of all submitted information.
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Text version
Attachment D – Experience Questionnaire: 12444626Q0061
USDA – Forest Service
EXPERIENCE QUESTIONNAIRE
(Ref. FSH 6309.31 and 41 USC 1)
INSTRUCTIONS: See Box 13, Remarks, if extra space is needed to answer any questions below. Mark “X” in appropriate boxes.
1. CONTRACTOR NAME, ADDRESS, AND TELEPHONE NO.
UEI (Formerly DUNS #) _____________________ E-Mail #_____________________
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 in contracting have you or your business had as a (a) prime contractor ____ and/or (b) sub-contractor ____?
6. List below the projects your business has completed within the last three years:
CONTRACT
AMOUNT TYPE OF PROJECT/DESCRIPTION
DATE
COMPLETED
NAME, ADDRESS, AND TELEPHONE NO. OF
OWNER/PERSON TO CONTACT FOR PROJECT
INFORMATION
7. List below all of your firm’s contractual commitments running concurrently with the work contemplated by this solicitation:
CONTRACT
NUMBER
DOLLAR AMT.
OF AWARD
NAME, ADDRESS, AND TELEPHONE NO. OF
BUSINESS/GOVERNMENT AGENCY INVOLVED
AWARDED
(Units)
PERCENT
COMPLETED
DATE CONTRACT
COMPLETED
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. If “Yes” to either item 8a or 8b specify location(s) and reason(s) why:
Previous edition is obsolete (OVER) FS-6300-27 (3/00)
9. Organization and work that will be available for this project.
a. (1) Minimum number of employees: _____ and Maximum number of employees: _____
b. Are employees regularly on your payroll: Yes No
c. 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:
INDIVIDUAL’S NAME
PRESENT
POSITION
YEARS
OF EXP.
MAGNITUDE AND TYPE OF WORK
11. List all the equipment (including vehicles) you plan to use on this contract. Provide a detailed description of the Equipment including your maintenance plan.
12. Contractor Inspection/Quality Control, Safety Plan, and Proposed Schedule. Describe Contractor Self Inspection Procedures which you will use to insure quality for this contract. Please include information on the purchase and use of any bio-based products & materials to be used on this project, a brief safety plan, and your planned schedule of work.
13. Remarks. Specify Box Numbers (Attach sheets if extra space is needed to fully answer any above question):
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 name 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
File details come from the government source that posted it. Updated .