Exhibit B - Past _ Present Past Performance Questionaire.docx

EXHIBIT B of Solicitation

PAST AND PRESENT PERFORMANCE QUESTIONNAIRE INSTRUCTIONS TO CONTRACTOR

Complete the CONTRACTOR INFORMATION section, below (type answers into light blue shaded boxes). Save the document. Send an electronic or hard copy print of the form to each of your reference contacts, asking them to please complete the form and submit it according to the instructions, below. It is preferred that these are the same clients/projects that you provided with Exhibit A for ease of evaluation and comparison. Projects should be relevant (within the same magnitude of construction) and recent (within the last five (5) years).

INSTRUCTIONS TO REFERENCE CONTACT

The contractor named below is submitting an offer for a United States Department of Veterans Affairs contract requirement, and has sent this form to you, in your role as a past performance reference contact. Please complete this form in full (all areas shaded in light yellow, below). Once completed, please send the form to the Contract Specialist via postal mail or email, directly to:

Department of Veterans Affairs Gulf Coast Veterans Health Care System NCO 16 Contracting Office ATTN: Cynthia Kinsman, Contracting Officer (REF: 36C25621R0172) 400 Veterans Ave, Bldg T102 Rm A110 Biloxi, MS 39531-2410

Email Address: Cynthia.Kinsman@va.gov

Please return the completed form no later than the time set for receipt of proposals. If you have any questions, please contact Cynthia Kinsman via email, or call 228-523-5062. Thank you for your assistance in this matter.

GENERAL INFORMATION [completed by Contractor]

Contractor Company Name

Street Address

Contractor Point of Contact Name

City

Point of Contact Phone Number

State

Reference Project Title

Zip Code

Contract Period of Performance (start to finish):

Email

Contract Number

Contract Dollar Value

629-18-107 Construct Surface Level Parking Lot, New Orleans Network Contracting Office (NCO) 16 Solicitation No. 36C25621R0172 FOR OFFICIAL USE ONLY Source Selection Sensitive Information—See FAR 2.101 & 3.104

Description of Work (was work for VA or Non- VA work)

Role of Contractor on This Project (check appropriate box)

□ Prime Contractor Sub-contractor Key Personnel

RESPONDENT INFORMATION [completed by Reference Contact]

Company Name

Street Address

POC Name

City

Phone Number

State

Fax Number

Zip Code

Email

PERFORMANCE INFORMATION: Choose the number on the scale of 1 to 6 that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY RATINGS OF 1 OR 2 in the applicable text box OR in the Remarks section, below (text box will expand to whatever extent is necessary).

Narrative:

the referenced contract? If yes, explain outcome in “remarks.”

YES

NO

please explain in “remarks.”

YES

NO

YES

NO

REMARKS (Please use as much space as is needed – the box will expand as you type).

Printed Name Title:

Signature