Form_1a_Past_Performance_Questionnaire.pdf

PAST PERFORMANCE QUESTIONNAIRE – FORM 1A

NOTE: IAW: Procurement Instruction Letter: (PIL) 2012-01. THE CONTRACTOR MAY COLLECT AND RETAIN

COMPLETED QUESTIONNAIRES FROM CLIENTS FOR SUBMITTAL TO THE GOVERNMENT. AFTER

COMPLETION OF THIS FORM, THIS FORM MAY BE DUPLICATED BY THE CONTRACTOR. THE

GOVERNMENT RESERVES THE RIGHT TO VERIFY ANY AND ALL INFORMATION.

Contractor Information Contractor to complete Blocks 1-4

Firm Name: _________________________________ Address: _________________________________________________ Phone Number: _________________________________:

Point of Contact: _____________________________Contact Phone Number: _________________________________

Work Performed as: Prime Contractor Sub Contractor Joint Venture Other (Explain)

Percent of project work performed: _________________________________ If subcontractor, who was prime (Name/Phone #): __________________________________________

Contract Information

Contract Number: _________________________________ Delivvery/Task Order Number (if applicable) : _________________________________ Title: : _________________________________ Location: _________________________________

Award date (mm/dd/yy) : _________________________________ Completion Date (mm/dd/yy) : _________________________________

Award Amount: _____________________________________________________ Final Price: : _________________________________

Project Description:

Client Information Client to complete Blocks 5-8

Name: _________________________________ Title: _________________________________ Phone Number: _________________________________ Email Address: _______________________

Describe the client’s role in the project:

Date Questionnaire was completed:

Client’s Signature:

FA6675-14-R-0004

Attachment for FA6675-14-R-0004