Past Performance Questionnaire.doc

Contractor’s Name: _____________________________ Contract Number: _____________________________

PAST PERFORMANCE QUESTIONNAIRE

A. General Information: Please correct any information below known to be inaccurate:

Contractor’s Name: ________________________________________________________________ Address: ________________________________ Telephone Number: ___________________

Fax Number: _________________________ Point of Contact: _______________________________________

Contract Number: ______________________________________ Contract Period or Dates of Performance and Dollar Amount (See Notes):

Basic Period of Performance: _______________________Amount: __$_______________

Option Period One of Performance: __________________Amount: __$_______________

Option Period Two of Performance: __________________Amount: __$_______________ Option Period Three of Performance: _________________Amount: __$_______________

Option Period Four of Performance: __________________Amount: __$_______________ Total Contract Amount: _$__________________________

Project Title: ____________________________________________________________

Description of Work (include approximate number of machines): ________________________________________________________________________________

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

Notes

(1) When assessing past performance, only performance that occurred within the last three (3) years prior to the issuance date of this solicitation (F3V3E12121A001 ) will be considered. As part of our evaluation, past performance information older than 3 years will not be considered. Most recent contracts must have been performed for at least 6 months prior to the issuance date of this solicitation to be considered.

(2) If offeror holds or has held other contracts for Washers and Dryers Maintenance, Repair and Lease services with your agency/organization in the last 3 years, please complete separate evaluation forms for those contracts as well.

(3) If the total dollar amount of the contract was/is for more than one year, indicate the dollar value for each year/option period and then give the total value of the contract.

B. Respondent Information:

Name of Respondent: _____________________________Title: __________________________________

Address: ______________________________________________________________________________

Telephone Number: ___________________________Fax Number: ________________________________

E-mail Address: ________________________________________ C. Mail, Electronically Mail, or Fax Completed Survey Form to the address below. The survey needs to be received no later than 4:00 pm Central Standard Time (CST) on Friday, August 03, 2012:

Address:

82d Contracting Squadron

Attn: Carrie E. Dilks 206 J Avenue, Bldg 1662 Sheppard AFB TX 76311-2743 E-Mail:

carrie.dilks@sheppard.af.mil or james.beeson@sheppard.af.mil Fax: 940-676-6709 D. Performance Information: Choose the appropriate letter on the scale (E, G, S, M, U, and N) that most accurately describes the contractor’s performance or situation. Please provide a narrative explanation for any ratings that are Exceptional, Marginal or Unsatisfactory.

Performance meets contractual requirements and exceeds many to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor was highly effective.

Performance meets contractual requirements and exceeds some to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

Performance was not observed or not applicable to the current effort being reported against.

Assign a Performance Rating by placing an “X” in the appropriate column

Comments:

If Yes, please provide comments:

Yes/No

If Yes, please provide comments:

Yes/No

Yes/No

Yes/No

If No, please provide comments:

Yes/No

Yes/No

How would you rate contractor’s overall performance?

Additional Remarks: _______________________________________________________

SOURCE SELECTION INFORMATION IAW FAR 3.104

FOR OFFICIAL USE ONLY

ATTACHMENT III