Atch_4,_Past_Exp_Reference_Sheet.doc

PAST EXPERIENCE QUESTIONNAIRE

This Acquisition is for the Cleaning of the U.S. Government Household Appliances at Einsiedlerhof Air Station.

A.

GENERAL INFORMATION: Please correct any information below known to be inaccurate:

Contractor’s Name:

Address:

Telephone Number:

Email Address:

Point of Contact:

Project Title or Brief Description of Work*:

Contract Number*:

Contract Amount:

Contract Period or Dates of Performance*:

Contractor performed as the ( Prime Contractor ( Sub-Contractor

To be completed by the respondent and returned directly to the contracting office.

* 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.

SPECIFIC EXPERIENCE INFORMATION:

What Type of Household Appliances were cleaned:

Description of Services Performed: ________________________________________________________________

Number of Household Appliances cleaned: ________________________________________________________

For Official Use Only