J.11 HCaTS SB Contractor Team Arrangement Form A01.pdf

Contractor Team Arrangement Form Human Capital and Training Solutions Small Business (HCaTS SB)

Solicitation: GS02Q15CRR0002 Amendment Number: 01 Attachment J.11

General: This form is to be sent to the members of the Offeror's existing or previous Contractor Team Arrangement (CTA) to validate the Offeror's performance under a contract, task order or purchase order awarded to the CTA. This form shall be signed by the majority of members in the CTA. The Government will use this information solely for source selection purposes under the HCaTS RFP.

CTA Team Members: You are receiving this form because the Offeror cited in Section I claims that they performed work on the contract, task order or purchase order identified in Section II as a member of your CTA and is using this work in support of a Relevant Experience Project for its HCaTS proposal. The Offeror is using this form to identify which portion of the contract, task order or purchase order was either solely completed by it or was managed by it. By signing this form in Section V you are certifying that the Offeror performed all work identified in Section IV and that no other CTA member or the CTA shall claim credit for this portion of the CTA's contract, task order or purchase order. By completing this form, you are not required to make changes to any existing documents or systems related to the contract, task order, or purchase order awarded to your CTA. If you have any questions about this document, please email hcats@gsa.gov.

Offeror: Section I, II, III, and IV shall be completed by the Offeror. To fill this form, place the cursor in the highlighted area and begin typing. All responses in Section II, III and IV shall match what is entered into Attachment J.5.1 (Self Scoring Worksheet Pool 1) and/or J.5.2 (Self Scoring Worksheet Pool 2) for the corresponding Relevant Experience Project. After completing Sections I, II, III and IV the Offeror shall send this form to the CTA members and shall be signed by at least the majority of members, excluding the Offeror. After receiving the completed form, you must save this document to your computer as a pdf file and name this file in accordance with Section L.4.1.

SECTION I. COMPANY INFORMATION

Type your answer for this section regarding the contractor:

Company Name Division Name DUNS Number

Street Address, City, State, Zip Code, Country

SECTION II. CONTRACT, TASK ORDER, OR PURCHASE ORDER

Type your answer for this section regarding the contract, task order or purchase order that was awarded to the CTA:

A. Contract/Task Order/Purchase Order: B. Award Date (mm/dd/yy):

a) Contract/Task Order/Purchase Order Number: C. Total Estimated/Obligated Value:

b) Contract Number (If using a task order or purchase order with a master contract): D. Period of Performance (mm/dd/yy):

From: To: , or ongoing

E. Project Type: F. Customer:

G. Contracting Office/Procurement Office: H. Assessing Official:

Email of Assessing Official:

I. If CTA performed as a First-Tier Subcontractor, there is a mutually binding legal relationship document between the CTA and Prime Contractor:

Solicitation: GS02Q15CRR0002 Amendment Number: 01 Attachment J.11

SECTION III. CONTRACTOR TEAM ARRANGEMENT

Type your answer for this section regarding the CTA:

A. Contractor Team Arrangement Name: C. Filename of CTA Agreement:

B. DUNS Number: D. Number of CTA Team Members:

SECTION IV. OFFEROR'S PERFORMANCE

Type your answer for this section regarding the Offeror's performance on the contract, task order, or purchase order from Section II. All prompts and responses refer to the Offeror's individual performance:

A. Period of Performance:

Begin Date:

Completion Date: or ongoing:

Duration in Months: Months

C. NAICS Code:

D. Contains Cost-Reimbursement Type: Yes No

B. Total Obligated/Estimated Dollars:

Total Value of Performed Work:

E. Number of subcontracting and teaming partners:

F. How many KSAs are represented in this project:

G. Fill out the KSA information for the KSA(s) that were represented:

HCaTS consists of three KSAs:

KSA 1: This KSA covers any type of customized training and development requirements and their respective life cycles, which can be performed at any level. (refer to Section C.3.1.1).

KSA 2: This KSA covers any type of customized human capital services and their respective life cycles, which can be performed at any level (refer to Section C.3.1.2).

KSA 3: This KSA covers any type of customized organizational performance improvement requirements and their respective life cycles, which can be performed at any level (refer to Section C.3.1.3).

KSA 1 Present: Yes, explain below No

- How does this project represent KSA 1? - How was the work that represented KSA 1 customized?

KSA 2 Present: Yes, explain below No

- How does this project represent KSA 2? - How was the work that represented KSA 2 customized?

KSA 3 Present: Yes, explain below No

Attachment J.11

- How does this project represent KSA 3?: - How was the work that represented KSA 3 customized?:

Offeror Certification: I certify that Section IV represents the portion of the contract, task order or purchase order stated in Section II that was either performed or managed by the Offeror named in Section I.

Company Name:

Authorized Representative:

Title:

Email:

Phone Number:

Signature: Date:

(This form shall be signed with a certified digital-signature or ink-signature.)

SECTION V. Contractor Team Arrangement Member's Certification Each CTA member shall have their primary point of contact that is designated in the CTA agreement certify by signing below that they are a CTA member of the CTA identified in Section II, and that the Offeror stated in Section I performed or managed all work claimed in Section IV and that no other CTA member or the CTA shall claim credit for this portion of the CTA's contract, task order or purchase order identified in Section II. Each CTA Member that chooses to sign this form will fill out one of the CTA Member boxes, sign and date and send back to the Offeror.

CTA Member #1:

CTA Member Name: DUNS Number(if Available):

Address:

Primary Point of Contact:

Title:

Email:

Phone Number:

Signature: Date:

(This form shall be signed with a certified digital-signature or ink-signature.)

CTA Member #2:

CTA Member Name: DUNS Number(if Available):

Address:

Primary Point of Contact:

Title:

Email:

Phone Number:

Signature: Date:

(This form shall be signed with a certified digital-signature or ink-signature.)

Attachment J.11

CTA Member #3:

CTA Member Name: DUNS Number(if Available):

Address:

Primary Point of Contact:

Title:

Email:

Phone Number:

Signature: Date:

(This form shall be signed with a certified digital-signature or ink-signature.)

CTA Member #4:

CTA Member Name: DUNS Number(if Available):

Address:

Primary Point of Contact:

Title:

Email:

Phone Number:

Signature: Date:

(This form shall be signed with a certified digital-signature or ink-signature.)

CTA Member #5:

CTA Member Name: DUNS Number(if Available):

Address:

Primary Point of Contact:

Title:

Email:

Phone Number:

Signature: Date:

(This form shall be signed with a certified digital-signature or ink-signature.)

CTA Member #6:

CTA Member Name: DUNS Number(if Available):

Address:

Primary Point of Contact:

Title:

Email:

Phone Number:

Signature: Date:

(This form shall be signed with a certified digital-signature or ink-signature.)

Attachment J.11

CTA Member #7:

CTA Member Name: DUNS Number(if Available):

Address:

Primary Point of Contact:

Title:

Email:

Phone Number:

Signature: Date:

(This form shall be signed with a certified digital-signature or ink-signature.)

CTA Member #8:

CTA Member Name: DUNS Number(if Available):

Address:

Primary Point of Contact:

Title:

Email:

Phone Number:

Signature: Date:

(This form shall be signed with a certified digital-signature or ink-signature.)

CTA Member #9:

CTA Member Name: DUNS Number(if Available):

Address:

Primary Point of Contact:

Title:

Email:

Phone Number:

Signature: Date:

(This form shall be signed with a certified digital-signature or ink-signature.)

CTA Member #10:

CTA Member Name: DUNS Number(if Available):

Address:

Primary Point of Contact:

Title:

Email:

Phone Number:

Signature: Date:

(This form shall be signed with a certified digital-signature or ink-signature.)