ATTACH_5_Experience_Form.docx

CUI//FEDCON [when filled in] Source Selection Information - See FAR 2.101 & 3.104 [when filled in]

FIRE SAFETY SYSTEMS MAINTENANCE AND REPAIR SERVICES AT MARINE CORPS BASE CAMP BUTLER, OKINAWA, JAPAN N40084-23-R-2004

ATTACHMENT 5

EXPERIENCE FORM

The offeror shall complete all sections in English.

EXPERIENCE DATA SHEET

Project No. (check one) : |_| #1 |_| #2 |_| #3 |_| #4 |_| #5

1. Experience for: |_| Offeror |_| Joint-Venture |_| Other (Explain)

Firm Name:

Address:

Phone Number:

Point of Contact: Contact Phone Number:

2. Work Performed as: |_| Prime Contractor |_| Sub Contractor |_| Joint Venture |_| Other (Explain)

Percent of project work performed:

If subcontractor, who was prime (Name/Phone #):

3. Contract Number: Delivery/Task Order Number:

Title:

Location:

4. Award Date (mm/dd/yy): Completion Date (mm/dd/yy):

5. Type of work:

|_| Maintenance |_| Inspection |_| Repair |_| Test |_| Certification |_| Other (explain):

6. Type of Contract/Task Order: (Check ALL that apply)

|_| Firm-Fixed Price |_| Cost/Time and Material |_| Other (explain):

7. Award Amount: Final Price:

Type of Contract/Task Order: (Check ALL that apply)

|_| Delivery/Task Order (IDIQ) |_| Other (explain):

8. Provide a detailed description of the project and the relevancy to the project requirements of this RFP (Include applicable annex in accordance with Factor 1)

9. Provide a detailed description of what work your firm self-performed on this project:

10. Other Information:

CUI//FEDCON [when filled in] Source Selection Information - See FAR 2.101 & 3.104 [when filled in]