A-4 Sources Sought Info Req Form UF Jan 10.docx

Sources Sought Information Request Form - Page 1 of 2

Project Name: Selfridge Multiple Award Task Order Contracts (MATOC) Bonding requirement: $3M for individual project.

NAICS Code: 236220 and 237990

Interested firms please respond with this information form and the following requested information. Please complete all sections of the document.

1. Company Information:

Company name: _________________________________________________________ Company Address as registered in CCR:

( ) I have confirmed that my address listed above is exactly the same as listed in CCR ( ) The above address is not the same in CCR, but registration is being corrected to the above listed address

DUNS Number: ________________________________

Socio-economic status for the listed NAICS code - please check all that apply:

( ) Service-Disabled Veteran-Owned Small Business (SDVOSB)

The firm must be registered in CCR (www.CCR.gov) with the socio-economic status identified above and the NAICS code specified in the sources sought notice. If the firm’s CCR record does not include this project’s NAICS code, the firm will not be considered.

( ) I have confirmed that my firm is registered in CCR for the NAICS code and business type selected ( ) My firm is not registered in CCR with the NAICS code and business status selected, but the firm qualifies and registration is in process ( ) My firm is not registered in CCR for the identified NAICS code

2. Bonding Capability:

Individual Project Bonding: _____________________ Total Aggregate Bonding Capability: _____________________ This response must include a letter from your bonding company confirming this amount to be considered.

( ) Bonding letter and/or certificate from bonding provider for amount listed above is attached with my response ( ) My firm does not have a bonding capacity letter ( ) My firm cannot bond to the stated bond requirement

3. Examples of similar work:

( ) I have attached three references for similar work that our firm has performed. Past Performance Information should be submitted for projects conducted within the last 3 years and include: project title, Sources Sought Information Request Form - Page 2 of 2 location, whether work was as a prime or subcontractor, contract/subcontract dollar value, type of contract and percentage of self-performed work.

( ) I have not attached three references of similar work that our firm has performed.

Certification:

I understand that incomplete answers in sections or my failure to provide required documentation or failure to sign this certification may remove my firm from consideration for this project sources sought notice.

Signature:_____________________________________________ Name: ________________________________________________ Title: ________________________________________________ Phone Number: _______________________