Attachment_5 __Past_Performance_Form.docx

Offeror: _____________________________ RFQ #P16PS01587

PAST PERFORMANCE FORM

Use this form to demonstrate your successful past experience of relevant jobs that compare favorably to the work offered in this project. Refer to the Instructions for the Submission of Quotation and Other Information (Section L). List contracts and other pertinent work to describe how your experience is relevant to the requirements of this RFQ. Use as many copies of this Form, or an equivalent, as may be required. Attach additional documents as needed. If you have no relevant experience, you must state that on this form in order to qualify for a neutral rating.

PART I – FINANCIAL DATA

I.1 FINANCIAL DATA AS OF ________________ (date)

CURRENT ASSETS $_________________ Name of Bank: _________________

CURRENT LIABILITIES $_________________ Point of Contact: _________________

NET WORTH $_________________ Phone Number: _________________

PART II – EXISTING COMMITMENTS

II.1 CONTRACT NUMBER: AMOUNT:

AGENCY/OWNER:

CONTACT PERSON: PHONE NUMBER:

DESCRIPTION OF WORK:

PERFORMANCE PERIOD:

II.2 CONTRACT NUMBER: AMOUNT:

AGENCY/OWNER:

CONTACT PERSON: PHONE NUMBER:

PERFORMANCE PERIOD:

PART III – PAST PERFORMANCE & RELEVANT EXPERIENCE

III.1 CONTRACT NUMBER: AMOUNT:

AGENCY/OWNER:

CONTACT PERSON: PHONE NUMBER:

SPECIFIC AREAS OF EXPERIENCE WHICH RELATE TO THE WORK OF THIS PROJECT:

III.2 CONTRACT NUMBER: AMOUNT:

AGENCY/OWNER:

CONTACT PERSON: PHONE NUMBER:

SPECIFIC AREAS OF EXPERIENCE WHICH RELATE TO THE WORK OF THIS PROJECT:

III.3 CONTRACT NUMBER: AMOUNT:

AGENCY/OWNER:

CONTACT PERSON: PHONE NUMBER:

SPECIFIC AREAS OF EXPERIENCE WHICH RELATE TO THE WORK OF THIS PROJECT:

III.4 LARGEST CONTRACT IN THE PAST THREE YEARS

CONTRACT NUMBER __________________________

CONTRACT AMOUNT __________________________

CONTRACT DATE __________________________

AGENCY/OWNER: __________________________