REV_Attach_E_Past_Performance_Questionnaire.DOC

Attachment E

EXPERIENCE - PAST PERFORMANCE REFERENCE

(May be modified/formatted as needed but offeror’s proposal shall contain at a minimum all the information below.)

SOLICITATION NO. _____________________

PROJECT EXPERIENCE FORM

Please provide a completed form for each project for which experience is being claimed (Offeror fills out this section).

Name of Offeror: __________________________________________________

Name of Project: __________________________________________________

Location of Project: ________________________________________________

Contract Number Project Performed Under: _______________________ Task Order Number: ________

Was the Project Firm-Fixed Price or Cost Reimbursable (including Time & Materials)? _____________________________________________________________________________________________

Was the offeror the prime contractor or subcontractor? __________________________________________

If the offeror was the prime contractor, please explain primary role/duties: ________________________

Brief Description of Project (Offeror can add attachment provided page count is not exceeded.) _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Contract Amount at Award: _____________________________________________

Final Contract Amount: ________________________________________________

Amount added by Modification: _________________________________________

Explanation of any Cost Growth/Overruns:_____________________________________________________

Multiple Interim Schedule Milestones (to include scheduled start date): ___________________________

Original Contract Completion Date: ____________________________________

Final Contract Completion Date: _______________________________________

Actual Completion Date: ______________________________________________

Time added by Modification: ___________________________________________

Explanation of any Late Finish: _______________________________________________________________

Additional Project Information (Offeror can add attachment provided page count is not exceeded): _____________________________________________________________________________________________

Was the project terminated early or were cure/show cause letters received? FORMCHECKBOX Yes FORMCHECKBOX No Explain early termination (default/convenience) or cure/show cause letters.

Safety record: ____ Accidents, ____ Incidents, ____Violations

List and explain any customer concerns or dissatisfaction

What were the SDB, WOB and small business percent goals in the original contract, if any? N/A________SDB:______ WOB: _____ Small Business:______ HUBZONE: ______ SDVOSB: _______

What was the actual percent achieved at contract completion?

N/A______SDB: ______ WOB: _____ Small Business: _____ HUBZONE: ______ SDVOSB: _______

Was the project owner an agency of the federal government? FORMCHECKBOX Yes FORMCHECKBOX No

Name, address, FAX and telephone number of the owner:

Name and telephone number of a representative of your firm who is knowledgeable of this project and can readily be contacted:

Name, address, FAX and telephone number of a representative of the owner who is knowledgeable of this project and can be readily contacted:

Name, address, FAX and telephone number of the Contracting Officer if project was for federal government: