Appendix A - Work Sample Cover Sheet V2.docx

<<Input OFFEROR NAME>>

WORK SAMPLE COVER SHEET

PART I: WORK SAMPLE IDENTIFICATION

Contractor Name:

Contract Number:

Task Order Number (if applicable):

Subcontract Number (if applicable):

Customer:

Period of Performance:

Work Sample Value:

Work Sample Identifier (WS1, WS2, etc):

PART II: WORK SAMPLE INFORMATION/POINTS OF CONTACT

1. Contracting Officer Name:

Title:

Agency or Customer:

Phone Number:

Email Address:

2. Contracting Officer’s Representative or Relevant Customer Point of Contact Name:

Title:

Agency or Customer:

Phone Number:

Email Address:

3. Alternate Contracting Officer’s Representative or Relevant Customer Point of Contact Name:

Title:

Agency or Customer:

Phone Number:

Email Address:

PART III: PROJECT DESCRIPTION (1 page limit) Instructions to Appendix A – Work Sample Cover Sheet

DELETE THIS PAGE UPON COMPLETION OF THE WORK SAMPLE COVER SHEET

Offerors shall follow the instructions below when filling out Appendix A Work Sample Cover Sheet.

PART I: WORK SAMPLE IDENTIFICATION

Contractor Name: Offerors shall enter the Contractor’s Name of this work sample.

Contract Number: Offerors shall enter the Contract Number.

Task Order Number: Offerors shall enter the Task Order Number (if applicable).

Subcontract Number: Offerors shall enter the Subcontract Number (if applicable).

Customer: Offerors shall enter the agency, organization, or client name. If the customer was a Government agency, or organization, Offerors shall include the office symbol and program name this work sample supports.

Period of Performance: Offerors shall include the period of performance if the contract/order including all options. Offerors shall list the period of performance in the following format (MM/YYYY – MM/YYYY or MM/YYYY – Present):

Work Sample Value: Offerors shall enter the final or most recent total contract/order value of the work sample. The total value shall include the value of all options.

Was this Work Sample Performed as the Prime Contractor? The Offeror shall select ‘Yes’ if the Contractor listed under Contractor Name was the Prime under the work sample.

Work Sample Identifier: Works samples shall be numbered WS1-WS10. Insert the applicable work sample number.

PART II: WORK SAMPLE INFORMATION/POINTS OF CONTACT

Contracting Officer: Offerors shall provide the contact information for either the current Contracting Officer working the contract or the most recent Contracting Officer if the contract has ended. If there is no available Contracting Officer, then leave this section blank.

Contracting Officer’s Representative (COR) or Relevant Customer Point of Contact: Offerors shall provide the contact information for the Primary (or Alternate if Primary is not available) COR. If a COR is not available, or if the work sample is not for a Government contract, Offerors shall provide a relevant customer point of contact that would be able to assist in validation of the work sample.

Each Offeror shall provide at least two (2) Points of Contact for each work sample.

PART III: WORK SAMPLE DESCRIPTION (1 page limit) Offerors shall provide a brief description of the work sample. If the Offeror uses a subsidiary or legal entity work sample as a prime work sample, the Offeror may use this section to describe the relationship.

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