Y1DZ--Copy of FY 24 STX New Construction Proj 671-21147 / Repair and Level CLC Canopy Concrete Floor Audie L Murphy Hospital San Antonio (VA-24-00000541)

PAST PERFORMANCE QUESTIONNAIRE Solicitation Number: Project Title: CONTRACT INFORMATION (Contractor to complete Blocks 1-4) 1. Contractor Information Firm Name: CAGE Code: Address: DUNs Number: Phone Number: Email Address: Point of Contact: Contact Phone Number: 2. Work Performed as: Prime Contractor Sub Contractor Joint Venture Other Percent of project work performed: If subcontractor, who was the prime (Name/Phone #): 3. Contract Information Contract Number: Delivery/Task Order Number (if applicable): Contract Type: Firm Fixed Price Cost Reimbursement Other (Please specify): Contract Title: Contract Location: Award Date (mm/dd/yy): Contract Completion Date (mm/dd/yy): Actual Completion Date (mm/dd/yy): Explain Differences: Original Contract Price (Award Amount): Final Contract Price (to include all modifications, if applicable): Explain Differences: 4. Project Description: Complexity of Work High Med Routine How is this project relevant to project of submission? (Please provide details such as similar equipment, requirements, conditions, etc.) CLIENT INFORMATION (Client to complete Blocks 5-8) 5. Client Information Name: Title: Phone Number: Email Address: 6. Describe the client s role in the project: 7. Date Questionnaire was completed (mm/dd/yy): 8. Client s Signature: