PAST PERFOMANCE_EXPERIENCE FILLABLE QUESTIONNAIRE.pdf

PDF 177 KB Posted

Attached to
Wall Ranger District Janitorial Services Federal contract opportunity
Solicitation number
1240LP22Q0102
Issued by
Department of Agriculture Forest Service

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Experience Questionnaire

1. Contractor Name, Address, Telephone Number, and Email Address:

3. COMPANY INFORMATION

DUNS or UEI: __________________ Small Business: Yes No

Primary NAICS Code: _____________

3. How many years of experience do you or your company have in performing janitorial services? _____________

4. Please provide references for the last three (3) companies you have performed janitorial service.

Company and Name of Person Email Address Phone Number

6. List the name (s) of the key personnel who will be performing the cleaning services:

7. List below the experience of the key personnel who will be performing the work:

Individual’s Name Present Position Years of Experience

Type of Work

9. Past Performance - List below the projects your business has completed within the last five (5) years which are similar in scope and scale to this job:

Contract Number

Contract Amount

Location of Work Names, Telephone No., and Email of Owner/Person to contact for Project Information

Description of Project

Location of Work

Location of work

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

Contract # Dollar Amount Name, Tel, Email of Business/Govt Agency Involved

Location of work When will contract be completed?

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 Government with any information needed to verify my capability to perform this project.

13a. CERTIFYING OFFICIAL'S NAME AND TITLE

13b. SIGNATURE 14. DATE

1 Contractor Name Address Telephone Number and Email Address:
DUNS or UEI:
Primary NAICS Code:
3 How many years of experience do you or your company have in performing janitorial services:
3 How many years of experience do you or your company have in performing janitorial services_2:
Company and Name of PersonRow1:
Email AddressRow1:
Phone NumberRow1:
Company and Name of PersonRow2:
Email AddressRow2:
Phone NumberRow2:
Company and Name of PersonRow3:
Email AddressRow3:
Phone NumberRow3:
6 List the name s of the key personnel who will be performing the cleaning services:
Individuals NameRow1:
Present PositionRow1:
Years of ExperienceRow1:
Type of WorkRow1:
Individuals NameRow2:
Present PositionRow2:
Years of ExperienceRow2:
Type of WorkRow2:
Individuals NameRow3:
Present PositionRow3:
Years of ExperienceRow3:
Type of WorkRow3:
Contract NumberRow1:
Contract AmountRow1:
Location of WorkRow1:
Names Telephone No and Email of OwnerPerson to contact for Project InformationRow1:
Description of Project:
Contract NumberRow1_2:
Contract AmountRow1_2:
Location of WorkRow1_2:
Names Telephone No and Email of OwnerPerson to contact for Project InformationRow1_2:
Contract NumberRow1_3:
Contract AmountRow1_3:
Location of workRow1:
Names Telephone No and Email of OwnerPerson to contact for Project InformationRow1_3:
Description of Project_2:
Description of ProjectRow1:
Contract Row1:
Dollar AmountRow1:
Name Tel Email of BusinessGovt Agency InvolvedRow1:
Location of workRow1_2:
When will contract be completedRow1:
Contract Row2:
Dollar AmountRow2:
Name Tel Email of BusinessGovt Agency InvolvedRow2:
Location of workRow2:
When will contract be completedRow2:
Contract Row3:
Dollar AmountRow3:
Name Tel Email of BusinessGovt Agency InvolvedRow3:
Location of workRow3:
When will contract be completedRow3:
Contract Row4:
Dollar AmountRow4:
Name Tel Email of BusinessGovt Agency InvolvedRow4:
Location of workRow4:
When will contract be completedRow4:
13a CERTIFYING OFFICIALS NAME AND TITLE:
13b SIGNATURE:
14 DATE:
Text1:
Check Box1: Off
Check Box2: Off

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