D4 1282A720R0004_TechCapVerifForm.docx

TECHNICAL CAPABILITY VERIFICATION FORM

Solicitation No.: 1282A720R0004 | Schenck JCC Waste & Recycle Multi-Year Contractor Name

Date

☒ a. Designation of Representatives. Contractor shall provide the contact information for the Key Personnel (at minimum) required in the solicitation/contract terms, Section B.1.7.

Key Personnel In accordance with the above specified contract number, the following personnel are assigned to this contract:

Contracts Manager Overwrite Here Phone Overwrite Here Email Overwrite Here

Reserved. (Contractor may Change as Needed) Overwrite Here Phone Overwrite Here Email Overwrite Here

Project Manager Name Overwrite Here Phone Overwrite Here Email Overwrite Here

Inspector Name Overwrite Here Phone Overwrite Here Email Overwrite Here

Designated Representative The individual named below is designated as my representative for this contract and, in my absence, is authorized to act in my behalf.

Contracts Manager Overwrite Here Title Overwrite Here

This delegation extends authority to take any action necessary with respect to the execution of work, including acknowledging receipt of Notice to Proceed, Suspend and Resume Work Orders, and Notices of Noncompliance. The items check below indicates additional authority authorized by this delegation:

☐ Sign progress payment estimates and invoices.

☐ Sign contract modifications.

☐ Sign final payment estimate and invoice and contract release.

☐ Execute contract termination settlement agreement.

☐ Full authority in all contractual matters.

Name

Title

☒ b. Experience Questionnaire. Document experience in accordance with solicitation requirements using the data below.

DO NOT EXCEED THE SPACE PROVIDED.

1. Contractor Name, Address and Telephone No.

2. Business ☐ Company ☐ Co-partnership ☐ Corporation ☐ Individual ☐ Non-Profit Organization Date

(a) prime contractor ____ and/or (b) sub-contractor ____?

5. List below, a minimum of three (3) projects your firm has completed relating to this solicitation within the last three years:

(5a) CONTRACT

AMOUNT

(5b) TYPE OF PROJECT AND BRIEF DESCRIPTION (5c) NAME, ADDRESS, AND TELEPHONE NO. OF OWNER/PERSON TO CONTACT FOR PROJECT INFORMATION

6. List below all of your firm’s contractual commitments running concurrently with the work contemplated by this solicitation:

(6a) CONTRACT

NUMBER

(6b) DOLLAR AMT.

OF AWARD

(Date) (6e) PERCENT

COMPLETED

(6f) ANTICIPATED COMPLETE DATE

7a. Have you ever failed to complete any work awarded to you? ☐ Yes ☐ No 7b. Has work ever been completed by performance bond? ☐ Yes ☐ No 7c. If “Yes” to either item 8a or 8b specify location(s) and reason(s) why:

7d. Did you look at the project site(s) on-the-ground? ☐ Yes ☐ No

8. Organization and work that will be available for this project.

a. (1) Minimum No. of Employees: _____ and (2) Maximum No. of Employees: ______

b. Are employees regularly on your payroll: ☐ Yes ☐ No

9. Contractor Inspection. Describe Contractor Self Inspection Procedures which you will use to insure quality for this contract.

I certify that all of the statements made by me are complete and correct to the best of my knowledge and that any person’s name as references are authorized to furnish the Forest Service with any information needed to verify my capability to perform this project. ___________ (Initial)

Contractor Name

Date

☒ c. Proof of SAM Account Registration Status. This section is ONLY required for completion and return with the proposal package for Offerors without an Active SAM Account. If completing this section, the contractor must complete and return Section E.4, Representations, Certifications and other Statements of Offerors of the solicitation terms.

For Agency: USDA Forest Service Agency Contact: Klenise Wallace, klenise.wallace@usda.gov Type Here

SAM Account Request Date: _____________________________________Type Here

Anticipated Active Date: _____________________

Copy and Paste Here

I affirm that the knowledge contained herein is true to the best of my knowledge.

Type Here Type Here

Contractor Representative (Print Name) Signature & Date Signed

d. ☒ Certification. The items contained herein have been completed and are submitted in response to solicitation 1282A720R0004. By signing this certification, I certify that the information provided within this Technical Capability Verification Form for solicitation 1282A720R0004 is complete and true to the best of my knowledge.

Type Here

Company Name: _______________________________ Type Here

Representative’s Name: _________________________________ Type Here

Representative’s Phone: _________________________________ Type Here

Representative’s Email: ______________________________________ Type Here

Representative’s Signature: _______________________________ Date: _________________