Past Performance Questionaire Form for VA REV Nov 23

Past Performance List of References
Solicitation Information

RLP No.: 36C10F25R0024

Offers Due By (Date/Time):
VA Contracting Officer (Name/Email):
VA Broker (Name/Email):
Offeror Entity Name:

PAST PERFORMANCE LIST OF REFERENCES

In reference to column PPQ below, check the appropriate box (see RLP, Section 4.04, for submission instructions): A. Select A if VA Contract, Offeror using a previously completed PPQ B. Select B if VA Contract, Offeror submitted a PPQ request to the contract reference; include date of submission

C. Select C if Non-VA Contract

Contract
Past Performance Contractor Entity
Past Performance Reference
PPQ
Reference
Entity Name
UEI No.
Name/Title
Phone/Email
No.

Date PPQ
Submitted to
Reference

A

B

C

A

B

C

A

B

C

A

B

C

A

B

C

Past Performance List of References Form for VA (REV. 11/23)

Past Performance Questionnaire Form for VA

PART I. PAST PERFORMANCE QUESTIONAIRE (PPQ) COVER PAGE

RLP No.:

Offeror Entity Name:

1. CONTRATOR INFORMATION

Project Reference No.:
Contact Name:
Contact Phone/Email:

Entity Name:
Entity Address:

UEI No.:

2. GENERAL WORK INFORMATION

Work Performed For:
Customer Name (if Non-VA):
Work Performed As:
Percentage (%) of Work Performed:

3. CONTRACT DETAILS

Type of Contract:
Contract No.:
Contract Award Date:
Contract Completion Date:

If Other, Explain:
Place of Performance:
Price at Award:
Price at Completion:

4. REFERENCES

Contracting Officer/Signature Authority
Name:
Title:
Phone:
Email:

Resident Engineer/Technical Representative
Name:
Title:
Phone:
Email:

5. PROJECT DESCRIPTION

(Attach additional pages if needed)

Project Size:

Type of Facility/Work:

If Other, Explain:

Detailed Description of the Work Performed/Explanation of Relevancy to RLP Requirements:

Key Personnel Names/Roles (Indicate if Assigned to Current Solicitation): Major Subcontractor(s) Names/Roles:

6. OFFEROR CERTIFICATION OF PART I

I certify that the information provided in this PPQ is accurate and complete.

Signature
Past Performance Questionnaire Form for VA (REV. 11/23)

Date

Past Performance Questionnaire Form for VA

Requested by:

PART II (A). PAST PERFORMANCE QUESTIONAIRE INFORMATION

Completed by:

Date Completed:

1. CONTRACT DETAILS

Contract No.:
All contract details and description of work performed outlined in Part I of this PPQ is accurate: If not, please explain:
(additional space for comments is provided on page 4)

2. REFERENCES

Contracting Officer/Signature Authority
Name:
Title:
Phone: