Past Performance Questionnaire.pdf

USDA – Forest Service

PAST PERFORMANCE QUESTIONNAIRE

(Ref. FSH 6309.31 and 41 USC 1)

INSTRUCTIONS: See Box 11, Remarks, if extra space is needed to answer any questions below. Mark “X” in appropriate boxes.

1. CONTRACTOR NAME, ADDRESS, AND TELEPHONE NO.

2. SUBMITTED TO (office Name and Address)

3. BUSINESS

Company Co-partnership Corporation Individual Non-profit Organization

4. How many years do you or your firm have in the line of work contemplated by this solicitation?

5. How many years of experience in contracting have you or your business had as a (a) prime contractor ____ and/or (b) sub-contractor ____?

6. List below the projects your business has completed within the last three years:

CONTRACT

AMOUNT

TYPE OF PROJECT

DATE

COMPLETED

NAME, ADDRESS, AND TELEPHONE NO. OF

OWNER/PERSON TO CONTACT FOR PROJECT

INFORMATION

7a. Have you ever failed to complete any work awarded to you? Yes No 7b. If “Yes” to Item 8a type of project and reason(s) why:

8. Remarks. Specify Box Numbers (Attach sheets if extra space is needed to fully answer any above question):

CERTIFICATION

I certify that all of the statements made by me are complete and correct to the best of my knowledge and that any person named as references are authorized to furnish the Forest Service with any information needed to verify my capability to perform this project.

9a. CERTIFYING OFFICIAL’S NAME AND TITLE

b. SIGNATURE (Sign in ink) 10. DATE