Past and Present Performance Questionnaire

RESPONSIBILITY QUESTIONNAIRE

896416215184
The following information is needed to help evaluate and determine your company responsible. Please complete the following items and submit with your proposal: A. The names of up to three (3) customers/contracts that you have held or done business with, including points of contact and phone numbers.

Name of Customer/Contract:

Address:

Name of POC:

Telephone No:
Dates/Years of Performance:

Annual $ Value:

Services Performed/Additional Comments:

1371853172759

1371853172721

1371853172976

1371853171198

Name of Customer/Contract:

Address:

Name of POC:
Telephone No:

Dates/Years of Performance:

Annual $ Value:

Services Performed/Additional Comments:

1371853172707

1371853162826

1371853172722

Name of Customer/Contract:
Address:

Name of POC:

Telephone No:

Dates/Years of Performance:

Annual $ Value:

Services Performed/Additional Comments:

1371853172952

1371853171198

1371853172976

1371853172722

896416305422

FINANCIAL INSTITUTION REFERENCE SHEET

896416188013
Instructions to Contractor: Include with your proposal a reference sheet for each financial institution that you have a business account with. This sheet may be sent to the banking institution regarding a determination of contractor responsibility as part of the evaluation for award of this solicitation.

TO BE FILLED OUT BY CONTRACTOR:

COMPANY’S NAME:

Point of Contact (POC) Name: POC Phone Number:

INSTITUTION NAME:

POC name: POC title: POC phone number:
I give permission for the following information regarding my account/s at your institution to be released to representatives of the 5th Contracting Squadron, Minot AFB, North Dakota. 9147042891593658233289159
Name/TitleSignature/Date
914704291937
DO NOT HAVE THIS SECTION FILLED OUT. IF YOUR FIRM IS SELECTED AS THE POTENTIAL AWARDEE, THIS FORM WILL BE SENT TO YOUR BANKING INSTITUTION FOR COMPLETION.

TO BE FILLED OUT BY FINANCIAL INSTITUTION:

Please give amounts as a range – i.e. low four figures, mid six figures, etc. Average monthly balance in checking: Average monthly balance in savings: Amount of any current loans: Amount of any lines of credit: Any late payments or NSFs: How long with this institution: Credit rating with this institution: I verify that the information provided above is current as of .

9147042905663658233290566
Name/TitleSignature/Date