Experience Questionnaire

Attachment F – Experience Questionnaire

USDA – Forest Service

EXPERIENCE QUESTIONNAIRE (Ref. FSH 6309.31 and 41 USC 1)

INSTRUCTIONS: See Box 13, Remarks, if extra space is needed to answer any questions below. Mark “X” in appropriate boxes. 1. CONTRACTOR NAME, ADDRESS, AND TELEPHONE NO.

2. SUBMITTED TO (office Name and Address)

3. BUSINESS

Company  Co-partnership
Corporation  Individual
Non-profit Organization
4. How many years do you or your firm have in the line of work contemplated by this solicitation?

6. List below the projects your business has completed within the last three years:

CONTRACT

AMOUNT

TYPE OF PROJECT/DESCRIPTION

DATE

COMPLETED

NAME, ADDRESS, AND TELEPHONE NO. OF

OWNER/PERSON TO CONTACT FOR PROJECT

INFORMATION

7. List below all of your firm’s contractual commitments running concurrently with the work contemplated by this solicitation:

CONTRACT NUMBER

DOLLAR AMT. OF AWARD

NAME, ADDRESS, AND TELEPHONE NO. OF BUSINESS/GOVERNMENT AGENCY INVOLVED

AWARDED

(Units)

PERCENT

COMPLETED

DATE CONTRACT COMPLETED

8a. Have you ever failed to complete any work awarded to you?  Yes  No 8b. Has work ever been completed by performance bond?  Yes  No 8c. If “Yes” to either item 8a or 8b specify location(s) and reason(s) why:

Previous edition is obsolete (OVER) FS-6300-27 (3/00)

9. Organization and work that will be available for this project.

Are employees regularly on your payroll:  Yes  No
Estimate rate of progress below (such as 2.0 acres/man/day)

10. List below the experience of the principal individuals of your business:

INDIVIDUAL’S NAME

PRESENT

POSITION

YEARS

OF EXP.

MAGNITUDE AND TYPE OF WORK

11. List all the equipment (including vehicles) you plan to use on this contract. Provide a detailed description of the Equipment including your maintenance plan.

12. Contractor Inspection/Quality Control, Safety Plan, and Proposed Schedule. Describe Contractor Self Inspection Procedures which you will use to insure quality for this contract. Please include information on the purchase and use of any bio-based products & materials to be used on this project, a brief safety plan, and your planned schedule of work.

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

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 name as references are authorized to furnish the Forest Service with any information needed to verify my capability to perform this project.