A01_J4_ACC-APG_PP_QUESTIONNAIRE_R1.doc

FOR OFFICIAL USE ONLY

PAST AND PRESENT PERFORMANCE QUESTIONAIRE

When filled in this document is source selection sensitive IAW FAR 2.101 and FAR 3.104.

A. GENERAL INFORMATION: Please correct any information below known to be inaccurate:

Contractor’s Name:

Contractor puts their information here Address:

Telephone Number:

Fax Number:

Point of Contact:

Name, Title (President, CEO) Project Title or Brief Description of Work:* Information Technology Support Services to include installation, monitoring and support of LAN/WAN system components including site preparation, installation of hardware and software components, demonstration and training and troubleshooting of components such as: printers, PC, scanners, blackberry devices, laptops/notebooks, digital senders, copiers, VTC solutions, LAN drops, and Graphic Illustration support services.

Did this project include VTC Maintenance and Equipment Upgrading?

YES / NO

Did this project include VTC Maintenance and Repair?

YES / NO

Did this project include work with high definition cameras?

YES / NO

Did this project include VTC Bridge equipment?

YES / NO

Did this project include secure communication service?

YES / NO

Did this project include non-secure communication service?

YES / NO

Contract Number Provided by Offeror:

Dollar Amount *(Average cost per project/delivery order and life of contract cost): $ Contract *Period or Dates of Performance Provided by Offeror:

* NOTE: If offeror holds or has held other contracts with your agency/organization in the last 3 years, please complete separate evaluation form for those contracts as well.

Contractor performed as the __Prime Contractor __ Sub-Contractor __ Key Personnel

B. RESPONDENT INFORMATION:

Name of Respondent: _____________________________ Title: ____________________

Address: ____________________________ Telephone Number: ____________________

____________________________________ Fax Number: __________________________

____________________________________ Email Address: ________________________

C. PERFORMANCE INFORMATION:

Past Performance

Place an “X” in the appropriate column using the definitions matrix above.

Place provide rating using the definitions matrix above for Past Performance:

Acceptable OR Unacceptable

Remarks:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Note: While these questions are generic and will work as written in many acquisitions, consider them as they relate to each individual acquisition and tailor them as needed and appropriate. Also, when tailoring the form, consider leaving space between questions for comments.

CONTRACTOR’S NAME:

Information Management Help Desk Services

SOLICITATION NUMBER:

W91CRB-17-R-0023