Attachment_J.19_BioData_New_Format_.pdf

ATTACHMENT J.19

CONTRACTOR EMPLOYEE BIOGRAPHICAL DATA SHEET

1. Name (Last, First, Middle) 2. Contractor’s Name

3. Employee’s Address (include ZIP code)

4. Contract Number

5. Position Under Contract

6. Proposed Salary

7. Duration of Assignment

8. Telephone Number (include area code)

9. Place of Birth

10. Citizenship (NA)

11. EDUCATION (include all college or university degrees)

NAME AND LOCATION OF INSTITUTION MAJOR DEGREE DATE Positions Held Years of Experience

12. EMPLOYMENT HISTORY

1. Give last three (3) years. List salaries separate for each year. Continue on separate sheet of paper if required to list all employment related to duties of proposed assignment.

2. Salary definition – basic periodic payment for services rendered. Exclude bonuses, profit-sharing arrangements, commissions, consultant fees, extra or overtime work payments, overseas differential or quarters, cost of living or dependent education allowances.

POSITION TITLE

EMPLOYER’S NAME AND ADDRESS

POINT OF CONTACT &TELEPHONE #

Dates of Employment (M/D/Y) Annual Salary

From To

13. SPECIFIC CONSULTANT SERVICES (give last three (3) years)

SERVICES PERFORMED

EMPLOYER’S NAME AND ADDRESS

POINT OF CONTACT &TELEPHONE #

Dates of Employment (M/D/Y) Days at Rate

Daily Rate From To

14. CERTIFICATION: To the best of my knowledge, the above facts as stated are true and correct.

Signature of Employee

Date

15. CONTRACTOR'S CERTIFICATION (To be signed by responsible representative of Contractor)

Contractor certifies in submitting this form that it has taken reasonable steps (in accordance with sound business practices) to verify the information contained in this form. Contractor understands that THE COURTS may rely on the accuracy of such information in negotiating and reimbursing personnel under this contract. The making of certifications that are false, fictitious, or fraudulent, or that are based on inadequately verified information, may result in appropriate remedial action The Courts, taking into consideration all of the pertinent facts and circumstances, ranging from refund claims to criminal prosecution.

Signature of Contractor’s Representative Date