Sources_Sought_Information_Request_Form_17-R-0003.pdf

Sources Sought Information Request Form W912L7‐17‐R‐0003

Return to: sinamar.b.benauro.civ@mail.mil

Interested firms please respond with this information form and the following requested information.

Please complete all sections of the document

NAICS Code: ( ) 424410

1. Company Information:

Company name:

Company Address as registered in System for Award Management (SAM) (formally CCR):

( ) I have confirmed that my address listed above is exactly the same as listed in (SAM)

( ) The above address is not the same in (SAM), but registration is being corrected to the following Address:

Address:

DUNS Number: Cage Code:

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

( ) Large business ( ) Small business

( ) Small disadvantaged business ( ) 8(a) program participant

( ) HUB Zone business ( ) Woman‐Owned business

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

The firm must be registered in System for Award Management (SAM) https://www.sam.gov/portal/public/SAM/ with the socio‐economic status identified above and the NAICS code specified in the sources sought notice. If the firm’s (SAM) record does not include this project’s NAICS code, the firm will not be considered.

( ) I have confirmed that my firm is registered in SAM for the NAICS code and business type selected

( ) My firm is not registered in SAM with the NAICS code and business status selected, but the firm qualifies and registration is in process

( ) My firm is not registered in SAM for the identified NAICS code

2. Examples of similar performance:

( ) I have attached three references for similar services that our firm has performed.

A. The type of performance:

dollar value:

contract number:

location of project,:

Point of Contact(POC):

and POC email:

B. The type of performance:

dollar value:

contract number:

location of project,:

Point of Contact(POC):

and POC email:

C. The type of performance:

dollar value:

contract number:

location of project,:

Point of Contact(POC):

and POC email:

( ) No references attached.

( ) ___ references are attached.

4. A brief outline of resources, and key personnel that would be used to accomplish the required performance.

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 sources sought notice.

Signature:

Name:

Title:

Phone Number:

Email: