Attach_03_Work_References_Form.doc

WORK REFERENCES FORM (Offeror to complete all blocks)

OFFEROR’s INFORMATION

1. Offeror’s 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:

How is this project relevant to project of submission? (Provide details regarding client caseload size, and required technical and management skills)

CUSTOMER INFORMATION (Company for Whom the Work was Performed)

5. Customer Information Company Name/Address:

Point of Contact:

Title:

Phone Number:

Email Address:

6. Describe the customer’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