Pt 08J

FORM PT 08J (1) U.S. DEPARTMENT OF VETERANS AFFAIRS

PAST PERFORMANCE SURVEY FORM

Lessor __________ Gov’t. __________ __________ of __________ Pages

PROCUREMENT SENSITIVE –

Name of the Offering Entity for

DUNS of the Offering Entity for

1. Company Name of Awarded Entity for Past Performance Referenced Project:

2. DUNS of Awarded Entity for Past Performance Referenced Project:

3. Names and Titles of Key Personnel of Awarded Entity Associated with Past Performance Referenced Project:

4. Name and Address of Contracting Activity/Agency:

5. Contract Number:

6. Contract Type (Check all that apply): Negotiated_________ Sealed Bid_________

Other________(Identify Other)_________________________

7. Total Contract Amount:___________________

Status: Active_______ Complete__________ Lease Term (if applicable)________________

8. Date of Award: _________________________

Contract Completion Date (including any extensions):__________________ jshaw Typewritten Text SFO No. VA101-15-R-0222

9. Description and Location of Work provided. Important: describe relevancy to

10. List of Major Subcontractors and provide project/contract role:

11. Contracting Officer (CO) or Individual Responsible for Signing Contract

Name & Title:

Phone No.:

Email:

Address:

12. Project Manager and Telephone/Email Address:

jshaw Typewritten Text

VA101-15-R-0222

13. Resident Engineer/CO’s Technical Representative or Construction Supervisor:

14. Administrative Contracting Officer or Individual Responsible for Administering the Contact, if different from #11 above:

15. Past Performance Reference Check Questionnaire (Form Pt 08J(2)) Contact:

A SEPARATE RECORD MUST BE COMPLETED FOR EACH CONTRACT PERFORMED BY THE

OFFEROR AND/OR KEY PERSONNEL DURING THE PAST THREE (3) YEARS, AS WELL AS THOSE

CURRENTLY IN PROGRESS AND ACCOMPANIED BY A PAST PERFORMANCE REFERENCE CHECK

QUESTIONNAIRE (FORM PT 08J(2))