Contractor Information Form.pdf

(Rev. 03/13)

N4008424R0051

SOURCES SOUGHT – SOC / CONTRACTOR INFORMATION FORM for

ASBESTOS LEAD SAMPLING SERVICES CONTRACT AT VARIOUS U.S. BASES AND

FACILITIES THROUGHOUT JAPAN

Use this form to provide contractor’s general information. Please limit response to two pages. The box at the bottom of this form may be used to clarify any requested information.

1. Contractor Information:

Firm Name:

Address:

Year firm established:

Name of POC for firm: Phone Number of POC:

Email of POC:

SAM Registered: □ Yes □ No

Unique Entity ID: CAGE Code:

2. Specify Qualifications for Conducting Business in Japan Type of Qualification of □ Your company

□ Your subcontractor(s) (Name: ) Comments if any (Optional):

(Check and fill if applicable)

3. Technical Capability – Do you have the capability to provide one or both of the following services:

(A) Sampling: □ Yes □ No Comments if any (Optional):

(B) Testing and laboratory services □ Yes □ No Comments if any (Optional):

4. Additional comments if any (Optional):

Form may be expanded. Please DO NOT change content of the form.

SOURCES SOUGHT – CONTRACTOR INFORMATION FORM for

ASBESTOS LEAD SAMPLING SERVICES CONTRACT AT VARIOUS U.S. BASES AND

FACILITIES THROUGHOUT JAPAN

Use this form (one per project) to provide supporting information that demonstrates project experience relevant to the subject announcement. Submit up to 5 projects. Please limit response to two pages per project.

1. Contractor Name:

2. Project No. (check one): - 1 - 2 - 3 - 4 - 5

3. Contract Number: Delivery/Task Order No.:

Project Number:

Title:

Location:

4. Award Date (mm/dd/yy): 5. Final Contract Price: ¥ Completion Date (mm/dd/yy): (incl. all options and mods) Project is % complete (on submission due date) This is the total project subcontract price.

6. Type of work: Facilities Support Certifications for Sampling required on this project

7. Customer/Owner Name:

Point of Contact Name/Title:

(person with project knowledge)

POC Phone Number: POC Email Address:

8. Were you the Prime contractor for this project? Yes No Were you a subcontractor for this project? Yes No

If subcontractor, who was the Prime contractor?

9. Type of Contract (check all that apply):

Firm Fixed-Price (FFP) Indefinite Delivery / Indefinite Quantity (IDIQ) Other (explain):

If partnership, provide the following information:

Partner firm name: Years working together:

Address:

10. Narrative Description of the Project:

11. Percentage of work you self-performed on this project: %. Explain work self-performed: