D.4 Past Performance Contacts.docx

DOCX document 99 KB Posted Aug 11, 2022

Attached to: G004--WICHITA/HCHV EMERGENCY HOUSING SERVICES (VA-22-00053279)
Solicitation number: 36C25522Q0210
Issued by: Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 15

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File	Type	Posted
36C25522Q0210_2.docx	DOCX document	Aug 11, 2022
D.1 QASP_.pdf	PDF	Aug 11, 2022
D.3 IMMIGRAT_CERT_make pdf.docx	DOCX document	Aug 11, 2022
D.2 WDOL_2015-5751_Rev 17_3-15-22 02.docx	DOCX document	Aug 11, 2022

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Offeror: _____________________ Past Performance Survey

Provide a minimum of three current/past performance references below for Health Care for Homeless Veteran (HCHV) services conducted within the past three years, to include the names and phone numbers of responsible individuals who would have firsthand knowledge of the performance. The Government reserves the right to review other past performance records. Records found with unsubstantiated unsatisfactory past performance history may assess the offer as technically unacceptable.

Business Name: _____________________________________________________________

Business Address: ___________________________________________________________

Contact Person: ___________________________ Title: ____________________________

Telephone Number: _________________________ Contract Value: $__________________

Contract Number/Reference: ___________________________________________________

Contract Period of Performance Dates: ___________________________________________