A002 Attachment__Pgs M-7 to M14 in Word..doc

Page M-10

Work Experience Form – Factors 1 and 2 (Completed & submitted by Offeror)

Factor 1 – Geographically relevant Experience

Factor 2 - Recent and relevant highway/road construction experience (work elements)

Directions: Complete this form for EACH project submitted for evaluation that meets or exceeds the stated criteria for Factor 1and/or Factor 2 (see page M-3 and M-4 for the evaluation criteria.) Submit this completed form with your proposal.

Offeror Information:

Company Name:

Company Address:

Point of Contact:

Phone Number:

*E-mail Address:

*Company Website:

* This information is optional

Project Information:

Project Name

Contract Number

Is this project located in SE Alaska? ( )YES ( ) NO

Definition: Southeast Alaska begins at the state line south of Ketchikan and extends north along the Alaska Panhandle to Yakutat.

Project Location (Town/State/Forest…)

Owner/Agency

Agency Contact:

Contact Phone #:

Contract Information for this project:

Our firm was the PRIME:

YES

NO

If PRIME, list # of subcontractors

Contract Award Date:

Contract Start Date:

Original Completion Date:

Final Completion Date:

# of Contract Modifications

Work Elements found in this project (submitted by Offeror) NOTE: If this project will not be used to show us your experience in the following work elements, do not complete this page.

NOTE: Use this form or an equivalent size document. Documents exceeding the size of this form will be truncated before evaluation.

Material source development

Organic material (muskeg) subexcavation

Fish pipe installation Fish pipe installation

(cont)

Aggregate production

Aggregate Placement

Shot Rock Production

Paving

Contract Management Past Performance (Completed and submitted by Offeror)

Directions: Complete this form for EACH project submitted for evaluation that meets or exceeds the stated criteria for Factor 3 (see page M-5). In addition, you must ensure the government agency, private contractor submits the Contract Management Past Performance Questionnaire (see pages M-13 & M-14) for this project.

Company Information:

Company Name:

Company Address:

Point of Contact:

Phone Number:

*E-mail Address:

*Company Website:

* This information is optional

Past Performance Project Information:

Project Name

Contract Number

Project Location

Owner/Agency Address:

Revised by A002

Owner/Agency:

Contact Name:

Contact Phone No

Date Questionnaire Form for this project sent to this Agency/owner:

Contract Information for this project:

Our firm was the PRIME:

YES

NO

If PRIME, list number of subcontractor:

Contract Award Date:

Contract Start Date:

Original Completion Date:

Final Completion Date:

# of Contract Modifications

Work completed by the offeror: (enter % and $ value)

INSTRUCTIONS for Narrative. Submit a narrative in the following format:

Submit 3 hardcopies as follows:

· Page 1 of this form

· Page 2 of this form, Narrative, answering the questions. You may use the block below or attach 1 page of text and 1 page of photos.

· Maximum 1 page text

· Maximum 1 pages photos.

· 8 ½” by 11” sheets of paper.

· Each page of each copy should contain the following legend: “Source Selection Information”

When is this form submitted?

Completed document should be submitted with your initial proposal.

Narrative – Answer these questions:

(Begin narrative below or attach similar document to first page of this form)

1a. Did your firm have other projects under construction during the performance of this contract? ( ) Yes ( ) No

1b. If “yes”, briefly describe the other project(s) including type of work, award amount, Owner/agency, and describe the skills used by your firms when managing these multiple projects.

2a. Did this project have multiple work sites that were under construction simultaneously? ( ) Yes ( ) No

2b. If yes, describe the skills used when managing this project with multiple sites.

Project Past Performance Questionnaire (Part A - Completed by Offeror & sent to Owner/Agency)

(Parts B & C - completed & submitted by Owner/Agency)

Directions Part A – To be completed by the Offeror, who then sends form to Owner/Agency.

Parts B & C – To be completed by the Owner/Agency and submitted directly to:

ATTN: Julee McTaggart

FAX: (360) 619-7932

(Mailroom – do not open) PHONE: (360) 619-7584

Federal Highway Administration E-MAIL: wfl.contracts@fhwa.dot.gov 610 East Fifth Street

Vancouver, WA 98661-3801

Part A - General Information (to be completed by the Offeror):

Contractor’s Name

Contractor Address

Owner/Agency

Contact Name:

Contact Phone Number:

Project Title

Project Number

Contract Number

Project Location

What work did Contractor perform under this contract?

Part B - Contract Information for project listed above (to be completed by the Owner/Agency):

Contract Award Date:

Contract Start Date:

Original Completion Date:

Final Completion Date:

Project Past Performance Questionnaire (Completed and submitted by Owner/Agency)

Evaluation Factor Rating System. Please provide ratings and comments regarding the Contractor’s performance in each area below using the following ratings:

N/A=Not Applicable U=Unsatisfactory P=Poor F=Fair G=Good E=Excellent O=Outstanding

· Unsatisfactory--Response to inquiries, technical/service/administrative issues is not effective

· Poor--Response to inquiries, technical/service/administrative issues is marginally effective

· Fair--Response to inquiries, technical/service/administrative issues is somewhat effective

· Good--Response to inquiries, technical/service/administrative issues is usually effective

· Excellent--Response to inquiries, technical/service/administrative issues is effective

· Outstanding--The contractor has demonstrated an outstanding performance level that justifies adding a point to the score. (It is expected that this rating will be used in those rare circumstances where contractor performance clearly exceeds the performance levels described as "Excellent".)

For ratings of “Unsatisfactory” and “Poor” please provide a brief explanation in the remarks section.

Part C - Rating for project listed on reverse (to be completed by the Owner/Agency):

Remarks:

Source Selection Information

See FAR 2.101 and 3.104

(Applicable when filled-in)