Attachment_5_-_QUESTIONNAIRE_-_22_January_2014_-_WORD.doc

22 January 2014

Page of 4

PAST AND PRESENT PERFORMANCE QUESTIONNAIRE

*Source Selection Sensitive IAW FAR 2.101 and FAR 3.104

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.

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.

RESPONDENT INFORMATION:

Name of Respondent: Title: Address: Telephone Number: Fax Number: Email Address:

EMAIL COMPLETED SURVEY FORM TO:

julie.berrelez@us.af.mil

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

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: