Contractor Information and Reference Form.pdf

CONTRACTOR SHALL COMPLETE AND SUBMIT WITH OFFER.

REFERENCE INFORMATION

SOLICITATION NUMBER:

HSCG31-12-Q-PIR024

DATE

COMPANY INFORMATION (Company name, address)

Are you registered with the Central Contractor Registry (CCR), current ly SAM (www.sam.gov)? Y_____ / N_____(If no, SAM registration must be completed and proof provided w/offer). Please provide your Dun & Bradstreet No

(DUNS):_____________________________________

telephone number:

cell phone number:

FACSIMILE NUMBER:

e-mail address:

1. LIST EXPERIENCE IN THIS TYPE OF WORK

2. HAVE YOU EVER BEEN TERMINATED FROM ANY JOB? (If YES, give reason)

3. DO YOU ANTICIPATE ANY DIFFICULTIES FINISHING THIS JOB ON TIME? (If YES, give reason)

4. PERCENTAGE OF WORK TO BE SUBCONTRACTED

6. REFERENCES Offer shall furnish the information listed below for like of similar contracts held with the U.S. Coast Guard, other Government Agencies or private industry. Failure to furnish this information may result in a determination of non-responsibility.

(LIST THREE)

6a. Reference #1:

Company name

Person to contact

Address

Telephone no.

Project

6b. Reference #2:

Company name

Person to contact

Address

6c. Reference #3:

Company name

Person to contact

Address http://www.sam.gov/