A.01.30_-_Appendix_D_-_Project_Experience_Form_-_26JAN2016.docx

APPENDIX D

PROJECT EXPERIENCE FORM

Control No.: W912PL-16-R-0011

OFFEROR’S NAME:

Provide a completed form for each project for which experience is being claimed. Experience provided for (check more than one box if applicable):

[ ] Offeror:

[ ] Key Subcontractor:

Was project a firm-fixed-price contract (Y/N)?

If No, what type was it?

Project Name:

Project Location:

Owner/Client: __________________________________________________________________

For this project for which experience is being claimed, firm(s) worked as the [ ] prime contractor; or [ ] Subcontractor. If experience is provided for more than one firm, check more than one box as appropriate for each firm listed.

Brief description of project (Include, as applicable, how project is similar in scope and magnitude to the work required in this RFP)

Contract Amount: ________________________ Original Contract Completion Date: ________________________ Final Contract Completion Date: ________________________ Actual Completion Date: ________________________ Percent of Completion: _________________________ Explanation of any Late Finish:

Was the project terminated early or were cure/show cause letters received? ___Yes ___No Explain early termination (default/convenience) or cure/show cause letters

Safety record: ____Injuries with Lost Workdays*, ____Injuries without Lost Workdays* (*Use the number reported on OSHA Form No. 200 or equivalent) List and explain any customer concerns or dissatisfaction. Explain how you responded.

SMALL BUSINESS SUBCONTRACTING (Complete for Offeror (Prime Contractor) only):

Large Business Offerors Only: What were t\he various small business percentage goals in the original contract, if applicable (see FAR 52.219-9)? SDB: _______ WOB: _______

Small Business: _______ Veteran-owned: _______ HUBZone: _______ What was the actual percent achieved at contract completion? SDB: _______ WOB: _______ Small Business: _______ Veteran-owned: _______ HUBZone: _______ Explanation—If goals were not met: