Experience Information Form.doc

EXPERIENCE INFORMATION

(To be completed by Contractor)

1. Contractor Name

Address:

2. Contract /Task Order(TO) /Purchase Order (PO) Number:

3. Contract/TO/PO Dollar Value: $

Contract/TO/PO Dollar Value w/MOD’s: $

4. Contract/TO /PO Status: Active Complete

Completion Date (w/extensions):

Project Title: Location:

Project Description-- to include the role of the contractor on the project and specific responsibilities of the contractor in performance of the effort.

Did the contractor serve as the prime contractor or sub-contractor on this project?

Project Owner or Project Manager for the Client –provide:

Name:

Address:

Telephone Number and E-mail: