J-1_Past_Performance_Worksheet.doc

CORPORATE EXPERIENCE and PAST PERFORMANCE INFORMATION FORM Form ___ of ___

Name of Offeror:

Contract Number, order number, or identifier:

Customer Name & Location:

Customer Point of Contact (Name & Title):

Telephone Number (PLEASE VERIFY):

and e-mail address

Number of personnel (FTE) performing per year (avg.):

To:

Detailed description of the work performed sufficient to demonstrate the relevance of the reference to the solicitation:

Quality, delivery, or cost problem(s); corrective action(s) taken; and effectiveness of the corrective action(s):

QUALITY

NOTE: An explanation must accompany all answers with an asterisk(*).

Was consideration or a monetary withhold for non-conforming supplies/services or late deliveries assessed against this contract? YES * (Explanation)

NO

Was/is any part of this contract terminated for default and/or in litigation?

YES * (Explanation)

NO

Was any warranty work completed on delivered items?

YES * (Explanation)

NO

Did you receive any quality awards in the past three years?

YES * (List Awards)

NO

TIMELINESS

Were all items (including products, services, reports, etc.) delivered within the original contract schedule?

YES NO * (Explanation)

OTHER PERTINENT INFORMATION

Describe any corrective action(s) initiated to solve any of the above-described problems/deficiencies on this contract. Discuss the success of the corrective action(s) taken.

Subcontractor(s) Utilized in Performance of this contract, description of the extent of work performed by subcontractor(s), along with annual dollar value of all subcontracts: