12-R-0027 Experience Information Form.docx

EXPERIENCE INFORMATION

(To be completed by Contractor Providing the Information)

1. Contractor For Which Information is Being Provided:

Name:

Address:

2. Contract /Task Order(TO) /Purchase Order (PO) Number:

3. Contract/TO/PO Dollar Value:

4. Contract/TO /PO Status: |_| Active |_| Complete

Completion Date (w/ extensions):

5. Project Title:

Location:

6. Project Description-- to include the role of the contractor on the project and specific responsibilities of the contractor in performance of the effort:

7. How is the project (above) relevant to the project contained in the RFP?

8. Project Owner or Project Manager for the Client – provide:

Name:

Address:

Telephone Number and E-mail:

FOR OFFICIAL USE ONLY. SOURCE SELECTION INFORMATION. SEE FAR 3.104