N4008419T0411_form_N4008419T0411.pdf

(Rev. 03/13)

SOURCES SOUGHT – CONTRACTOR INFORMATION FORM for

Preventive Maintenance Program and Service Orders for Gas Station Equipment and Underground Storage Tank, U.S. Naval Installations in KANTO Plain, JAPAN

Use this form to provide contractor’s general information. Please limit response to one page. The box at the bottom of this form may be used to clarify any requested information.

1. Contractor Information:

Firm Name:

Address:

Name of POC for firm:

Phone Number of POC: Email of POC:

2. System for Awards Management:

DUNS Number: ___________________ Cage Code: __________________

3. This space may be used to provide any additional information that is relevant:

(Rev. 03/13)

SOURCES SOUGHT – CONTRACTOR INFORMATION FORM for Preventive Maintenance Program and Service Orders for Gas Station Equipment and Underground

Storage Tank, U.S. Naval Installations in KANTO Plain, JAPAN

Use this form (one per project) to provide supporting information that demonstrates project experience relevant to the subject announcement. Submit up to 5 projects. Please limit response to two pages per project.

1. Contractor Name:

2. Project No. (check one): - 1 - 2 - 3 - 4 - 5

3. Contract Number: Delivery/Task Order No.:

Project Number:

Title:

Location:

4. Award Date (mm/dd/yy): 5. Final Contract Price: $

Completion Date (mm/dd/yy): (incl. all options and mods)

Project is % complete (on submission due date) This is the total project subcontract price.

6. Type of work: Facilities Support Maintenance/Overhaul/ Repair/ Alteration services

7. Customer/Owner Name:

Point of Contact Name/Title:

(person with project knowledge)

POC Phone Number: POC Email Address:

8. Were you the Prime contractor for this project? Yes No

Were you a subcontractor for this project? Yes No

If subcontractor, who was the Prime contractor?

9. Type of Contract (check all that apply):

Firm Fixed-Price (FFP) Indefinite Delivery / Indefinite Quantity (IDIQ)

Other (explain):

If partnership, provide the following information:

Partner firm name: Years working together:

Address:

10. Narrative Description of the Project:

11. Percentage of work you self-performed on this project: %. Explain work self-performed:

Form may be expanded. Please DO NOT change content of the form.