Attachment-5_PPIF.pdf

FA9301-15-R-0003

Attachment 5 20 Nov 2015

PAST PERFORMANCE INFORMATION FORM

Provide all information requested on this form for each contract/task order being submitted.

Provide brief and concise descriptions of your performance on the contracts/task orders you identify and use a separate form for each contract/task order. Limit the number of past efforts submitted to the limitations set forth in provision 52.212-1 of the solicitation.

A. Offeror Information:

Offeror Name (Company/Division): _____________________________________________

CAGE Code: _______________________________________________________________

DUNS Number: _____________________________________________________________

Estimate the percentage of the total proposed effort to be performed by this entity.

NOTE: If the company or division performing this effort is different than the Offeror or the relevance of this effort to the instant acquisition is impacted by any company/corporate organizational change, explain here:

B. Program Title:_______________________________________________________________

C. Contract Specifics:

Contracting Agency or Customer:________________________________________________

Contract Number/Task Order/Job Order:__________________________________________

Contract Type (Check all that apply: ☐ Fixed Price ☐ ID/IQ ☐ Cost ☐ Other (Specify)___________________

Role: ☐ Prime ☐ Subcontractor ☐ Other: (Specify)________________________

Job Disciplines:

☐GRAB Barrier Maintenance

☐Delta Bollard Maintenance

☐Other Barrier Maintenance

☐Other Bollard Maintenance

☐ Other: __________________________________________________________________

Contract Environment:

☐ Military Installation in California ___________________________________________

☐ Federal, State, or Local Government Agency __________________________________

☐ Other__________________________________________________________________

Period of Performance: From _______________________ To __________________________

Contract/Order/Project Amount: ___________________________________________________

If the above is an Indefinite Delivery type contract, please list the highest aggregate amount of all Task Orders performed concurrently under this contract:

Original Contract $ Value: $_____________________ (Do not include unexercised options)

Current Contract $ Value: $_____________________ (Do not include unexercised options)

If the amounts for 10 and 11 above are different, provide a brief description of the reason:

D. Brief Description of Effort as a Prime_____ Subcontractor ____ or Other _____

E. Completion Date:

Original Date: __________________________________________________________________

Current Schedule: _______________________________________________________________

Estimate at Completion: __________________________________________________________

How Many Times Changed: ______________________________________________________

Primary Causes of Change: _______________________________________________________

F. Primary Customer Points of Contact: (For Government contracts, provide current information on all three individuals. For commercial contracts, provide points of contact fulfilling these same roles).

Program Manager Name: _______________________________________________________

Office: _______________________________________________________________________

Address: ______________________________________________________________________

Phone: _______________________________________________________________________

Email: _______________________________________________________________________

Contracting Officer Name: _____________________________________________________

Office: ______________________________________________________________________

Address: _____________________________________________________________________

Phone: _____________________________________________________________________

Email: _____________________________________________________________________

Contract Administrator Name: ________________________________________________

Office: _____________________________________________________________________

Address: ___________________________________________________________________

Phone: _____________________________________________________________________

Email: _____________________________________________________________________