Attachment 5 -Experience Questionnaire

1. Contractor Name, email

Address, and phone number

USDA Forest Service

EXPERIENCE QUESTIONNAIRE

Instructions: See Box 10, Remarks, if extra space is needed to answer any item below. Mark “x” in appropriate boxes.

2. Submitted to (Office Name & Address)
Forest Service PPS
1019 N 5th St
Custer, SD 57730

4. How many years do you

or your firm have in the line
of work contemplated by this

3. Business type

Company Co-Partnership
Corporation
Individual
Non-profit Organization

5. How many years experience in contracting have you or your business had as a (a) prime contractor

6. List below the projects your business has completed within the last five years (or currently working) where we can confirm that your company has experience in similar work. Contract Amount
& Federal Contract #
if applicable

Type of Project

Ongoing or
Date
Completed

7b. Has work ever been completed by performance bond?
7c. If “Yes” to either item 7a or 7b specify location(s) and reason(s) why:

Person to Contact for Project
Information include email or
phone #

8. Organization and work that will be available for this project:

c. Specify equipment available for this contract

9. List below the experience of the principal individuals of your business: Individual’s Name
Present Position
Years of
Exp.
And City of Residence

Magnitude and Type of Work

10. Remarks—Specify Box Numbers (Attach sheets if extra space is needed to fully answer any above questions):

11. CERTIFICATION

I certify that all of the statements made by me are complete and correct to the best of my knowledge and that any persons named as references are authorized to furnish the Forest Service with any information needed to verify my capability to perform this project.
12a.Certifying Official’s Name and Title
12b. Signature (Sign in Ink)

13. Date