Past_Performance_Reference_Questionnaire.pdf

Past Performance Reference Questionnaire

Item Requested Information Information Provided by Reference

A. Contractor Name

Contractor Address

B. Agency Contract / Order Number

Prime/Subcontractor [ ] Prime [ ] Subcontractor

If Subcontractor, Prime Contractor Name

C. Contract / Order Type [ ] Competitive [ ] Sole Source

[ ] IDIQ [ ] Requirements [ ] Other

[ ] Fixed Price or Fixed Unit Price [ ] Cost Reimbursement

D. Initial Performance Dates From: To:

Extensions From: To:

From: To:

From To:

From: To:

E. Contract Canceled Prior to Scheduled End Date?

[ ] Yes [ ] No

F. Brief Description of Work

G. Reference Organization / Agency Name

H. Reference Organization Work Functions

I. Services Geographic Area [ ] Local [ ] County [ ] State [ ] National

Number of Locations

Past Performance Reference Questionnaire

Item Requested Information Information Provided by Reference

J. Contracting Official - Name Name:

Email:

Title

Address

Telephone

K. Reference Giver - Name Name:

Email:

Title

Address

Telephone

Fax

Role in acquisition process

Extent of contact with vendor personnel (e.g.

daily, weekly, etc.)

L. Reference Questions

M. Comments (Attach additional pages as necessary)

N. DOJ Reference Taker - Name

Contact Date (If taken over the Telephone)