M. Past Performance Questionnaire

867410653669000867410759777500867410867283000584200648335VA PAST PERFORMANCE QUESTIONNAIRE CONTRACT INFORMATION (Contractor/Offeror to complete Blocks 1-4)

1. CONTRACTOR/OFFEROR INFORMATION

Past Performance Reference No. (1-5):
Offeror Name:
Address:
Phone Number:DUNs Number:
Contact Name:
Email Address:Contact Phone Number:

2. GENERAL WORK INFORMATION

Work performed as:Offering EntityPredecessor Companies Key Personnel Percent (%) of project work performed by Offering Entity, Predecessor Companies or Key Personnel: List of Major Subcontractor(s) and Role(s):

3. CONTRACT INFORMATION

Contract Number:
Contractor Name Reference Contract Awarded To:Contractor DUNS Awarded: Agency/Customer: Delivery/Task Order Number (if applicable):
Contract Type:Firm Fixed PriceCost ReimbursementOther (Please explain) Contract Title: Contract Location:
Award Date (mm/dd/yy):
Construction Completion Date (mm/dd/yy):
Awardee Ongoing Services:
Original Contract Price (Award Amount):
Final Contract Price (to include all modifications, if applicable):

REFERENCE INFORMATION

Past Performance Questionnaire Reference Name & Title:
Phone No.:
Email:
Address:

Contracting Officer (CO) or Individual Responsible for Signing Contract Name & Title: Phone No.:
Email:
Address:

Resident Engineer/CO’s Technical Representative or Construction Supervisor Name & Title: Phone No.: Email: Address:

00VA PAST PERFORMANCE QUESTIONNAIRE

CONTRACT INFORMATION (Contractor/Offeror to complete Blocks 1-4)

1. CONTRACTOR/OFFEROR INFORMATION

Past Performance Reference No. (1-5):
Offeror Name:
Address:
Phone Number:DUNs Number:
Contact Name:
Email Address:Contact Phone Number:

2. GENERAL WORK INFORMATION

Work performed as:Offering EntityPredecessor Companies Key Personnel Percent (%) of project work performed by Offering Entity, Predecessor Companies or Key Personnel: List of Major Subcontractor(s) and Role(s):

3. CONTRACT INFORMATION

Contract Number:
Contractor Name Reference Contract Awarded To:Contractor DUNS Awarded: Agency/Customer: Delivery/Task Order Number (if applicable):
Contract Type:Firm Fixed PriceCost ReimbursementOther (Please explain) Contract Title: Contract Location:
Award Date (mm/dd/yy):
Construction Completion Date (mm/dd/yy):
Awardee Ongoing Services:
Original Contract Price (Award Amount):
Final Contract Price (to include all modifications, if applicable):

REFERENCE INFORMATION

Past Performance Questionnaire Reference Name & Title: