JULY 05
SOLICITATION FOR OFFERS
OUTPATIENT CLINIC
SFO NO. V101-183R-xxx-xxx-xx
[INSERT LOCATION OF FACILITY]
PAST PERFORMANCE SURVEY FORM
1.
Name and Address of Contracting Activity:
2. Contract Number: _____________________________
3. Contract Type (Check all that apply): Negotiated_________ Sealed Bid_________
Other________(Identify Other)_________________________
4. Total Contract Amount:___________________
Status: Active_______ Complete__________
5. Date of Award: _________________________
Contract Completion Date (including any extensions):__________________
6. Description and Location of Work:
7. List of Major Subcontractors:
8. Contracting Officer (CO) or Individual Responsible for Signing Contract and
Telephone/FAX Numbers:
9. Project Manager and Telephone/FAX Numbers:
10. Resident Engineer/CO's Technical Representative or Construction Supervisor and
Telephone/FAX Numbers:
11. Administrative Contracting Officer or Individual Responsible for Administering the
Contact, if different from #8 above, and Telephone/FAX Numbers:
A SEPARATE RECORD MUST BE COMPLETED FOR EACH CONTRACT AND
SUBCONTRACT PERFORMED BY THE OFFEROR AND KEY PERSONNEL DURING THE
PAST THREE (3) YEARS, AS WELL AS THOSE CURRENTLY IN PROGRESS.
Part IX Forms
Lessor __________ Gov't. __________
__________ of __________ Pages
PAST PERFORMANCE SURVEY FORM
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