Attachment_5_-_QUESTIONNAIRE_-_22_January_2014.pdf

PAST AND PRESENT PERFORMANCE QUESTIONNAIRE

*Source Selection Sensitive IAW FAR 2.101 and FAR 3.104

A. GENERAL INFORMATION:

Offeror Name (Company/Division): ____________________

CAGE Code: ______________________

DUNS Number: ____________________

Telephone Number: __________________

Address: __________________________ Fax Number: _________________________

__________________________ Point of Contact: ______________________

Project Title: _______________________________________________

Brief Description of Work: _____________________________________*

Contract Number Provided by Offeror: ___________________

Initial Contract Cost/Price: ____________________________*

Current/final Contract Cost/Price: _______________________*

Annual Contract $ Value: _____________________________

Contract Type: ______________________________________

Period of Performance: ______________________

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

22 January 2014 http://farsite.hill.af.mil/reghtml/regs/far2afmcfars/af_afmc/far/Far02.doc%23T2101 http://farsite.hill.af.mil/reghtml/regs/far2afmcfars/af_afmc/far/FAR03.DOC%23b3104

Primary Customer Points of Contact: (For Government contracts provide current information on all three individuals. For commercial contracts, provide points of contact fulfilling these same roles.)

Program Manager: (Name, Office, Address,Telephone)

Contracting Officer: (Name, Office, Address, Telephone)

Administrative Contracting Specialist: (Name, Office, Address, Telephone)

Completion Date:

Original date: ________________________

Current schedule: _____________________

Estimate at Completion: _______________

How Many Times Changed: _____________

Primary Causes of Change: ______________

* Note: If offeror holds or has held other contracts with your agency/organization in the last 3 years, please complete separate evaluation forms for those contracts as well.

B. RESPONDENT INFORMATION:

Name of Respondent: _____________________ Title: __________________________________ Address: _______________________________ Telephone Number: ______________________ Fax Number:____________________________ Email Address: __________________________

C. EMAIL COMPLETED SURVEY FORM TO:

julie.berrelez@us.af.mil

Subject: FA4887-14-R-0001 – Mess Attendant Services – Luke AFB AZ - Questionnaire

22 January 2014 mailto:julie.berrelez@us.af.mil

D. PERFORMANCE INFORMATION:

CONTRACTOR’S NAME: _______________ CONTRACT NUMBER: _______________

The Contractor:

1. Was the contractor ever issued a cure or show cause notice under the referenced contract? If yes, explain outcome in “remarks”.

YES/NO

2. Did the contractor ever receive a major complaint relating to personnel matters? If yes, explain in “remarks”.

YES/NO

3. Did the contractor ever receive a major violation regarding any safety or FDA Food Code violation?

YES/NO

4. Would you award another contract to this contractor? If no, explain in “remarks”. YES/NO

CONTRACTOR’S NAME: ___________________ CONTRACT NUMBER ______________

Remarks:______________________________________________________________________