Past Performance Questionaire.doc

CONTRACTOR’S NAME: ____________________________________

CONTRACT NUMBER: FA5587-08-R-0010_

PAST AND PRESENT PERFORMANCE QUESTIONNAIRE

When Filled In This Document Is Source Selection Sensitive IAW FAR 2.101 and FAR 3.104 SUBJECT: Request for Past Performance Evaluation

TO:

You have been identified as a point of contact for a past and/or present performance evaluation of the firm listed on the attached questionnaire. This firm is currently being considered for a FA5587-08-R-0010, Hospital Aseptic Management System contract at RAF Lakenheath, RAF Mildenhall and RAF Feltwell, United Kingdom.

Your prompt attention to this questionnaire will be greatly appreciated. If you have any questions concerning this request please contact TSgt Tina M. Jorae, tina.jorae@lakenheath.af.mil; SSgt Bonnie Yoakum, bonnie.yoakum@lakenheath.af.mil; or TSgt Rajendra Panchal, rajendra.panchal@lakenheath.af.mil.

Contracting Officer

1 Atch

Past and Present Performance Questionnaire

PAST AND PRESENT PERFORMANCE QUESTIONNAIRE

FA5587-08-R-0010

A. GENERAL INFORMATION

(The offeror will fill out section A and send it to their customers) Offeror’s Name: ____________________ Telephone Number: ____________________

Address: __________________________ Fax Number: _________________________

__________________________ Point of Contact: ______________________

Project Title and Brief Description of Work: _____________________________________

Contract Name/Number: ___________________ $/£ Amount: ______________

Contract Period: ______________________

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

B. CUSTOMER RESPONDENT INFORMATION:

Name of Respondent:

_____________________ Title: ____________________________

Company/Organization:_____________________________________________________

Address: _____________________

Telephone Number: ___________________ _____________________________ Fax Number:

Email Address: _____________________

C. FAX COMPLETED SURVEY FORM TO: _01638522268 local 0044638522268 from states or email to tina.jorae@lakenheath.af.mil &/or rajendra.panchal@lakenheath.af.mil &/or bonnie.yoakum@lakenheath.af.mil .

D. PERFORMANCE INFORMATION: Choose the appropriate letter on the scale that most accurately describes the offeror’s performance or situation.

Once completed this is Source Selection Information -- See FAR 2.101 and 3.104

Place an “X” in the appropriate column using the definitions matrix above.

Remarks:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

**Once completed this is Source Selection Information – see FAR 2.101 and 3.104