Past Performance Survey

ATTACHMENT 3

PAST OR PRESENT PERFORMANCE SURVEY

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

1. GENERAL BUSINESS INFORMATION

Date Firm Organized/Established:
Company President:

Vice President:

Is company a small business?

__

YES [ ] NO [ ] N/A [ ]

2. CONTRACTS/SUBCONTRACTS COMPLETED OR IN PROGRESS

Complete and submit the information requested on page 2-4 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.

ATTACHMENT 3

a. First Contract:
Contracting Agency or Company:
Point of Contact:

Telephone Number:

Contract Number:

Contract/Subcontract Amount: $

Project Title and Location:
General Scope of Project:
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):

How were the problems resolved?

ATTACHMENT 3

b. Second Contract:
Contracting Agency or Company:
Point of Contact:

Telephone Number:

Contract Number:

Contract/Subcontract Amount: $

Project Title and Location:
General Scope of Project:
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):

How were the problems resolved?

ATTACHMENT 3

c. Third Contract:
Contracting Agency or Company:
Point of Contact:

Telephone Number:

Contract Number:

Contract/Subcontract Amount: $

Project Title and Location:
General Scope of Project:
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):

How were the problems resolved?

ATTACHMENT 3

4. Certification of Past Performance Information:

Type or Print Information