J.5 Experience Questionnaire (2 Pages).pdf

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Attached to
Sunbeam Dam Stairs Federal contract opportunity
Solicitation number
1240LT26Q0006
Issued by
Department of Agriculture Forest Service

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This is a USDA Forest Service Experience Questionnaire form for federal contract solicitation 1240LT26Q0006, Project Name: Sunbeam Dam Stairs, located at Sawtooth National Forest.

The questionnaire is a template designed to evaluate contractor qualifications and capability to perform the project. It requires contractors to provide: contractor name, address, and telephone number; business structure classification (Company, Corporation, Co-partnership, Individual, or Non-profit Organization); years of experience in the line of work; years of experience as prime and sub-contractors; detailed project completion history for the last three years including contract amounts, project types, dates completed, and references; all concurrent contractual commitments with dollar amounts, awarded units, percentage completed, and contract completion dates; employment history including minimum and maximum number of employees, payroll status, available equipment, and estimated rates of progress; experience of principal individuals directly involved in the contract; and any previous work failures, performance bond completions, or on-the-ground site visits. The form also includes a certification section requiring the certifying official's name, title, signature, and date, with attestation that all statements are complete and correct to the best of the respondent's knowledge.

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USDA Forest Service

EXPERIENCE QUESTIONNAIRE

Instructions: See Box 11, Remarks, if extra space is needed to answer any item below, Mark “X: in appropriate boxes.

1. Contractor Name, Address, and Telephone Number

2. Submitted to (Office Name and Address) 3. Business [ ] Company [ ] Co-partnership [ ] Corporation [ ] Individual [ ] Non-profit Organization

4. How many years do you or your firm have in the line of work contemplated by this solicitation?

5. How many years experience have you or your business had as a (a) prime contractor ____ and/or (b) sub-contractor ____?

6. List below the projects your business has completed within the last three years:

Contract Amount

Type of Project Date Completed

Name, Address, and Telephone No. of Owner/Person to Contact for Project Information

7. List below all of your firm’s contractual commitments running concurrently with the work contemplated by this solicitation:

Contract Number

Dollar Amt.

of Award

Name, Address, and Telephone No. of Business/Government Agency Involved

Awarded (Units)

Percent Completed

Date Contract Complete

8a. Have you ever failed to complete any work awarded to you? [ ] Yes [ ] No 8b. Has work ever been completed by performance bond? [ ] Yes [ ] No 8c. Did you look at the project site(s) on-the-ground? [ ] Yes [ ] No 8d. If “Yes” to either item 8a. or 8b., specify location(s) and reason(s) why:

Solicitation No:

Project Name:

Forest/District:

EXPERIENCE QUESTIONNAIRE CONTINUED

9. Employees and equipment that will be available for this project:

a. (1) Minimum number of employees: _____ and (2) Maximum number of employees: _____

b. Are employees regularly on your payroll: [ ] Yes [ ] No

c. Specify equipment available for this contract:______________________________________________________

d. Estimate rate of progress below (such as 2.0 acres/man/day):

(1) Minimum progress rate:________________ and (2) Maximum progress rate: _________________________

10. List below the experience of the principal individuals of your business: (Who will directly be involved in this contract?)

Individual’s Name Present Position Years of

Experience Magnitude and Type of Work

11. Remarks -- Specify Box Numbers (Attach sheets if extra space is needed to fully answer any above question.):

NOTE: PLEASE PROVIDE ANY ADDITIONAL INFORMATION THAT WILL HELP EVALUATE YOUR ABILITY TO

SUCCESSFULLY COMPLETE THIS PROJECT.

CERTIFICATION

I certify that all of the statements made by me are complete and correct to the best of my knowledge, and that any persons named as references are authorized to furnish the Forest Service with any information needed to verify my capability to perform this project.

12a. CERTIFYING OFFICIAL’S NAME AND TITLE

b. SIGNATURE 13. DATE

2: Sunbeam Dam Stairs
3: Sawtooth National Forest
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