Attachment 5: RelevantExperienceSurvey 4pp

RELEVANT EXPERIENCE

Your Company Name:
Street Address:
City, State and ZIP Code:

1. GENERAL BUSINESS INFORMATION

Date Firm Organized/Established:
Company President: Vice President:
Is company a: Partnership [ ] Separate entity [ ] Division [ ] N/A [ ]

2. CONTRACTS / SUBCONTRACTS COMPLETED OR IN PROGRESS

Complete and submit the information requested below on prime contracts or subcontracts completed or in progress. Government contracts are preferred; but, if you have not performed Government contracts, indicate any other contracts completed or in progress.

a. First Contract:
Contracting Agency or Company:
Point of Contact: Telephone Number:
Project Title and Location:

Your Role (Prime [ ], Joint Venture [ ], or Subcontractor [ ]) and the work your firm performed:

Describe any Work You Subcontracted to Others:

Total Amount of Subcontract(s): $

Period of Performance: days
Scheduled Completion Date:
Actual Completion Date: Percentage of Work Completed: % Were You Terminated?

Quality Control or Safety Problems encountered (if any):

b. Second Contract:
Contracting Agency or Company:
Point of Contact: Telephone Number:
Project Title and Location:

Your Role (Prime [ ], Joint Venture [ ], or Subcontractor [ ]) and the work your firm performed:

Describe any Work You Subcontracted to Others:

Total Amount of Subcontract(s): $
Period of Performance: days
Scheduled Completion Date:

Actual Completion Date: Percentage of Work Completed: % Were You Terminated?

Quality Control or Safety Problems encountered (if any):

c. Third Contract:
Contracting Agency or Company:
Point of Contact: Telephone Number:
Project Title and Location:

Your Role (Prime [ ], Joint Venture [ ], or Subcontractor [ ]) and the work your firm performed:

Describe any Work You Subcontracted to Others:

Total Amount of Subcontract(s): $
Period of Performance: days
Scheduled Completion Date:
Actual Completion Date: Percentage of Work Completed: % Were You Terminated?

Quality Control or Safety Problems encountered (if any):

Type or Print Information

4. Certification of Past Performance Information: