Attachment_5_-_PPIF.doc

FA4528-18-Q-4045

Attachment 5

PAST PERFORMANCE INFORMATION FORM

The 5th Contracting Squadron, Minot AFB, North Dakota, is in the process of selecting a contractor for Cross-Connection Survey services. One of the considerations in proposal evaluation is the verification of the Offeror’s past and present performance on contracts, which reflect the Offeror's ability to perform on the proposed effort. We depend on information received from agencies such as yours, which have had firsthand experience with an Offeror, for the evaluation of the Offeror's performance on those contracts.

Please complete this form and providing comments wherever applicable. Please sign the document in the space provided. Please note, we may contact the Offeror on problem areas or concerns identified to see what corrective actions have been taken or will be taken. However, the individual's name completing the questionnaire will not be disclosed to the Offeror.

Please return the completed form as soon as possible but no later than the offer due date noted in the Solicitation. Please obtain this date from your Cross-Connection Survey contractor. The completed document should be marked Source Selection Sensitive/For Official Use Only. Forms submitted directly from the Contractor being evaluated will be thrown out.

Respondent and Contract Information:

Name of Customer/Contract:____________________________________________________________ Address: ___________________________________________________________________________

Name and Title of Evaluator:___________________________________________________________ Signature of Evaluator and Date:________________________________________________________ Telephone No:_______________________________________________________________________

Dates/Years of Performance: ___________________________________________________________ Annual $ Value:______________________________________________________________________ Contract Number: ____________________________________________________________________

Contractor performed as the ( Prime Contractor ( Sub-Contractor

Services Performed/Detailed Description of Work:__________________________________________ Did the contractor demonstrate the ability to hire, maintain, and replace, if necessary, qualified personnel?

How would you rate the contractor’s past performance? _________________________________________________________________________________ Would you award another contract to this contractor? If not, please explain:

Was the contractor ever issued a cure or show cause notice, or was the contract terminated? If yes, please explain: ________________________________________________________________________________ Is the contract rated in CPARS? Yes No

Remarks:________________________________________________________________________

SEND COMPLETED SURVEY FORM TO:

5 CONS/PKA

165 Missile Avenue, Minot AFB, ND 58705

ATTN: 1Lt Trenton M. High AND MSgt Nitra P. Latta

FAX: (701) 723-4172

EMAIL: trenton.high.1@us.af.mil and nitra.latta@us.af.mil

DUTY PHONE: (701) 723-3260