13-R-0004_Attachment_3_(PPQ)_Page_1.pdf

W912GB-12-R-0025

USACE PAST PERFORMANCE QUESTIONNAIRE ATTACHMENT 3

CONTRACT INFORMATION (Contractor to complete Blocks 1-4)

1. Contractor Information Firm Name:

Address:

Phone Number:

Email Address:

Point of Contact: Contact Phone Number:

CAGE Code:

DUNS Number:

2. Work Performed as: ❑ Prime Contractor Percent of project work performed:

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

❑ Sub Contractor

❑ Joint

Venture ❑ Other (Explain)

3. Contract Information Contract Number:

Delivery/Task Order Number (if applicable):

❑ Other (Please specify):

Contract Type: ❑ Firm Fixed Price ❑ Cost Reimbursement 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 (Client to complete Blocks 5-8)

5. Client Information Name:

Title:

Phone Number:

Email Address:

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

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

8. Client's Signature:

NOTE: USACE REQUESTS THAT THE CLIENT COMPLETES THIS QUESTIONNAIRE AND SUBMITS DIRECTLY BACK TO THE OFFEROR. THE OFFEROR WILL SUBMIT THE COMPLETED QUESTIONNAIRE TO USACE WITH THEIR PROPOSAL, AND MAY DUPLICATE THIS QUESTIONNAIRE FOR FUTURE SUBMISSION ON USACE SOLICITATIONS. CLIENTS ARE HIGHLY ENCOURAGED TO SUBMIT QUESTIONNAIRES DIRECTLY TO THE OFFEROR. HOWEVER, QUESTIONNAIRES MAY BE SUBMITTED DIRECTLY TO USACE. PLEASE CONTACT THE OFFEROR FOR USACE POC INFORMATION. THE GOVERNMENT RESERVES THE RIGHT TO VERIFY ANY AND ALL

INFORMATION ON THIS FORM