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SOLICITATION FOR OFFERS OUTPATIENT CLINIC SFO NO. VA-101-XX-RP-XXXX[INSERT LOCATION OF FACILITY]THIS PAGE INTENTIONALLY LEFT BLANK FOR REPRODUCTION PURPOSES.Lessor __________ Gov’t. ____________________ of __________ Pages
MAY 2009SOLICITATION FOR OFFERS OUTPATIENT CLINIC SFO NO. VA-101-XX-RP-XXXX[INSERT LOCATION OF FACILITY]PAST PERFORMANCE SURVEY FORM1. 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 andTelephone/FAX Numbers:9. Project Manager and Telephone/FAX Numbers:10. Resident Engineer/CO’s Technical Representative or Construction Supervisor andTelephone/FAX Numbers:11. Administrative Contracting Officer or Individual Responsible for Administering theContact, if different from #8 above, and Telephone/FAX Numbers:A SEPARATE RECORD MUST BE COMPLETED FOR EACH CONTRACT ANDSUBCONTRACT PERFORMED BY THE OFFEROR AND KEY PERSONNEL DURING THEPAST THREE (3) YEARS, AS WELL AS THOSE CURRENTLY IN PROGRESS.Part VIII: FormsLessor __________ Gov’t. ____________________ of __________ PagesPAST PERFORMANCE SURVEY FORM
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Department ofVeterans AffairsOffice
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MAY 2009SOLICITATION FOR OFFERS OUT
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Page 293 and 294: MAY 2009SOLICITATION FOR OFFERS OUT
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