Atch__-_Past_performance_Form.doc

RFP DOL-OPS-16-R-00036

Attachment 3- Past and Present Performance Information/Questionnaire

ATTACHMENT

PAST AND PRESENT PERFORMANCE INFORMATION REFERENCE FORM

REFERENCE INFORMATION (Offeror to complete this part and return with quote/proposal)

A. Offeror Information (Completed by the Offeror) Company Name: _______________________________________ Contact Name: ______________________________ Telephone Number: ________________________

Address: __________________________________ Fax Number: ____________________________

B. CONTRACT REFERENCE INFORMATION.

Each reference page must be supplemented with a separate page(s) that includes a description of the project and additional detail describing the effort involved. This information will assist the evaluators in assessing relevancy to the existing requirement. Note: The project title/description information may not to exceed one (1) additional page per reference.

REFERENCE #1:

Project Title: ____________________________________________________

1. Contract Number:

Delivery/Task Order Nr:

2. Contract Type: _______________________

3. Contract Dollar Value: (Base Year $__________________) ($_________________, including options)

4. Contract Period/ Dates of Performance: ____________________ (base + all option periods)

5. Contracting Officer Name

Phone Nr:____________________ Email Address: _____________________________________

6. Contracting Officer Technical Representative Name:

Phone Nr:

7. Contractor performed as the ( Prime Contractor ( Sub-Contractor ( Key Personnel.

REFERENCE #2:

Project Title: ____________________________________________________

1. Contract Number:

____________________Delivery/Task Order Nr:__________________

2. Contract Type: _______________________

3. Contract Dollar Value: (Base Year $__________________) ($_________________, including options)

4. Contract Period/ Dates of Performance: ____________________ (base + all option periods)

Phone Nr: ___________________________

6. Contracting Officer Technical Representative Name: __________________________________

Phone Nr: _______________________________________

7. Contractor performed as the ( Prime Contractor ( Sub-Contractor ( Key Personnel

REFERENCE #3:

Project Title: ____________________________________________________

1. Contract Number:

Delivery/Task Order Nr:

2. Contract Type: _______________________

3. Contract Dollar Value: (Base Year $__________________) ($_________________, including options)

4. Contract Period/ Dates of Performance: ____________________ (base + all option periods)

Phone Nr:____________________

6. Contracting Officer Technical Representative Name: _______________________________________

Phone Nr: _______________________________

7. Contractor performed as the ( Prime Contractor ( Sub-Contractor ( Key Personnel.

PAGE