Attachment 12 - PastPerformanceQuestionnaire - Amend 2.doc

HSCG84-12-R-BHQ003

PAST PERFORMANCE QUESTIONNAIRE

SOURCE SELECTION INFORMATION (FAR 3.104)

Please Return E-Mail or FAX to: U.S. Coast Guard, Emely Hagins, Contract Specialist

Email: emely.hagins@uscg.mil Tel: (510) 437-3057 Fax: (510) 437-3014

U.S. COAST GUARD

SHORE INFRASTRUCTURE AND LOGISTIC CENTER

PAST PERFORMANCE QUESTIONNAIRE

Solicitation Number: HSCG84-12-R-BHQ003 Name of evaluated firm: __________________________________________________ To Reference Organization: In accordance with the Government’s increased emphasis on past performance and experience as an evaluation factor, the U. S. Coast Guard is hereby requesting past performance and experience information on the above-listed firm that has listed you as a reference for the above Solicitation. The successful offeror will be required to fabricate and deliver Foam-filled Steel River Buoys.

Please complete the following Questionnaire and e-mail or FAX to the Coast Guard only at the above address.

Please do not send a copy to the firm.

( Thanking you in advance for taking the time to complete this survey and returning to the Coast Guard quickly but no later than 04/23/2012 2:00pm PST

CONTRACTOR PERFORMANCE QUESTIONNAIRE

A. IDENTIFICATION

1. Respondent Organization Name:

2. Address:

3. Phone Number:

Fax Number:

E-Mail:

4. Name & Title of Evaluator:

5. Contract/Subcontract Number:

6. Contract/Subcontract Amount (including all options):

7. Contract Type: FFP

Cost Reimbursable

Other (specify)

· Competitive ( ) Noncompetitive ( )

8. Period of Performance (including options, if applicable)

Attachment 12

Amendment 2 - Replacement Page