PPI List.doc

Name of Offeror : ____________________________________

PRESENT/PAST PERFORMANCE REFERENCE LIST履行履歴表

1. Name of Contracting Activity

契約の相手方/注文主

2. Name and title of point of contact (POC); Contracting Officer or/and Government Inspector/commercial project manager’s phone/Fax number, and e-mail address

契約担当者の氏名、役職と連絡先

例）米軍契約官または検査官、官公庁の

契約担当者または技師長など。

Tel:

Fax:

e-mail:

Tel:

Fax:

e-mail:

Tel:

Fax:

e-mail:

3. Contract number and project title 契約番号その他の識別番号

4. Total contract value 契約金額合計

5. Performance period (e.g. date/month/year through date/month/year) 契約期間 （自 至 ）

6. Description of contract work performed

(Scope of work; Internal Medicine Physician to provide services required for US Government beneficiaries/On-Base Hospitals/ Internal Medicine Physician to provide services required for other than On-Base Hospitals)

主な業務の内容

7. Contractor’s contract manager or supervisory technicians 請負業者の責任者または技師長

8. Comments (optional) その他の特記事項

RFP No. FA5209-08-R-0043, Attachment No. 3