Attach_0003_Work_References.doc

WORK REFERENCES FORM (Offeror to complete all blocks)

CONTRACT INFORMATION

1. Contractor Information

Firm Name:

Address:

Phone Number:

Email Address:

Point of Contact: Contact Phone Number:

2. Work Performed as: Prime Contractor Sub Contractor Joint Venture Other (Explain)

Percent of project work performed:

If subcontractor, who was the prime (Name/Phone #):

3. Contract Information Contract Number:

Delivery/Task Order Number (if applicable):

Contract Type: Firm Fixed Price Cost Reimbursement Other (Please specify):

Contract Title:

Contract Location:

Award Date (mm/dd/yy):

Contract Completion Date (mm/dd/yy):

Actual Completion Date (mm/dd/yy):

Explain Differences:

Original Contract Price (Award Amount):

Final Contract Price (to include all modifications, if applicable):

Explain Differences:

4. Project Description:

Complexity of Work High Med Routine How is this project relevant to project of submission? (Please provide details such as similar equipment, requirements, conditions, etc.)

CLIENT INFORMATION

5. Client Information Company Name/Address:

Point of Contact:

Title:

Phone Number:

Email Address:

6. Describe the client’s role in the project:

7. Date Questionnaire was completed (mm/dd/yy):

Revised April 2011

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Attachment 0002

SOURCE SELECTION SENSITIVE INFORMATION