Contractor_Information_and_Reference_Form.doc

CONTRACTOR INFORMATION AND REFERENCE FORM

SOLICITATION NumBER:

HSCG31-15-Q-LBA004

Date company information (Company name, address) Are you registered with the System for Award Management (SAM)? Y______ / N_______ ***YOU SHALL BE REGISTERED IN ORDER TO BE CONSIDERED FOR AWARD*** 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:

6c.

Reference #3: