Attachment_1.pdf

ATTACHMENT 1 EXPERIENCE REPORTING FORM

Tracking Number: Form No.___of ____ (e.g. 1 of 12)

Provide the following information to identify projects your company completed within the last five years that show experience with projects of similar type and scope. Use one form per project.

a. Does the experience claimed on this form derive from projects that were executed using native, in-house skills and resources? Yes No.

b. If the experience claimed is from other sources (you answered “no” above), check the appropriate box below which most closely identifies the relationship:

Teaming Arrangement Partnership Sub-Contractor

c. Name of Offeror:

d. Contract Number, Title and Location of Project:

e. Contract Type and Pricing Arrangement:

f. Type of System Installed

g. Reference (Client) Contact Information (includes POC name, address, phone, and email address):

h. Describe how the contract referenced is relevant to the immediate acquisition. If only portions of the contract are relevant, specify which portions of the contract are relevant to the immediate acquisition:

i. Describe your Role (Prime, Joint Venture, or Subcontractor, etc.):

j. Your Contract or Subcontract Amount: ($)

k. Detailed Description of Your Self-Performed Work (include percentage of total cost):

l. Describe any Work You Subcontracted to Others (include names, addresses, and values):

m. Dates Your contract: Began: Completed:

n. Your Performance Evaluation Rating, if known:

o. Were you ever issued a Cure or Show Cause Letter? yes no.

If “yes”, provide explanation:

p. Were you Terminated or Assessed Liquidated Damages? yes no.

If “yes”, provide explanation: