Past Performance Questionnaire.docx

Attachment – Past Performance INSTRUCTIONS TO PRIME CONTRACTOR: (Contractor submitting quote):

Complete the CONTRACTOR INFORMATION section. Save the document. Send an electronic or hard copy print of the form to each of your reference contacts, asking them to please complete the form and submit it according to the instructions, below.

Company Name

Street Address

Point of Contact

City

Point of Contact Phone Number

State

E-Mail Address

Zip Code

INSTRUCTIONS TO REFERENCE CONTACT

Please complete the following pages as a past performance Reference Contract for the entity named above. Once completed, please return the form to: Kelley Cunningham at Kelley.Cunningham@va.gov.

RESPONDENT INFORMATION [completed by Reference Contact]

Government Agency or Company name

Street Address

POC Name

City

Phone Number

State

Fax Number

Zip Code

Email

Contract Number

Prime or Subcontractor

Dollar Value

Period of Performance

Description of services provided

Location of services provided

PERFORMANCE INFORMATION: Choose the number on the scale of 0 (Neutral) to 5 (Exceptional) that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE AN EXPLANATION FOR THE OVERALL RATING in the Remarks section, below (text box will expand to whatever extent is necessary).

REMARKS (Please use as much space as is needed – the box will expand as you type).

I hereby certify that the information that I have reported above is accurate to the best of my knowledge.

Printed Name

E-mail address

Business Title

Signature

Date