Offeror Information for Personal Services Contracts with Individuals

OMB No.

Expiration Date:

OFFEROR INFORMATION FOR PERSONAL SERVICES CONTRACTS WITH INDIVIDUALS

The Privacy Act Statement is found at the end of this form.

Section A – Offeror Information
1. Title of Solicited Position      			2. Offeror’s Proposed Base Salary      						3. Solicitation Number      
4a. Last Name      				4b. First and Middle Names      
5a. Mailing Address      							6. Phone Numbers (include area code if within the United States of America) 6a. Daytime      
5b. City      		5c. State      			5d. Zip Code      		6b. Evening      
5e. Country (If not within the United States of America)      
7. Email Address (if available)      
Section B – Work Experience Describe your paid and non-paid work experience related to this offer. Do not attach job descriptions. Base Salary definition – basic compensation for services rendered, excluding bonuses, profit-sharing arrangements, commissions, consultant fees, extra or overtime work payments, overseas differential or quarters, cost of living or dependent education allowances.
1. Job Title (if Federal, include series and grade)      
2. From (mm/yyyy)      	3. To (mm/yyyy)      				4.Base Salary $     	per      		5. Hours per week      
6. Employer’s Name and Address      							7. Supervisor’s Name and Phone Number 7a. Name      
							7b. Phone      
8. May we contact your current supervisor? Yes No If we need to contact your current supervisor before making an offer, we will contact you first.
9. Describe your duties, accomplishments and related skills (if you need to attach additional pages, include your name, address, and solicitation number)      
Section C – Additional Work Experience Continue on a separate page if required to list all employment relating to the duties of the position.
1. Job Title (if Federal, please include series and grade)      
2. From (mm/yyyy)      	3. To (mm/yyyy)      				4.Base Salary $     	per      		5. Hours per week      
6. Employer’s Name and Address      							7. Supervisor’s Name and Phone Number 7a. Name      
							7b. Phone      
8. May we contact your current supervisor? Yes No If we need to contact your current supervisor before making an offer, we will contact you first.
9. Describe your duties, accomplishments and related skills (if you need to attach additional pages, include your name, address, and solicitation number)      

Section D - Education

1. Last High School (HS)/GED school. Give the school’s name, city, state, Zip code (if known), and year of diploma or GED received:      

2. Mark highest level completed: Some HS HS/GED Associate Bachelor Master Doctoral

3. Colleges and universities attended. Do not attach a copy of your transcript unless requested.

Total Credits Earned Semester Quarter

Major(s)

Degree (if any), Year Received

3a. Name      

     

     

     

     

City      

State      

Zip Code      

3b. Name      

     

     

     

     

City      

State      

Zip Code      

3c. Name      

     

     

     

     

City      

State      

Zip Code      

Section E – Other Education Completed Do not list degrees received solely on life experience or obtained from schools with little or no academic standards.

     

Section F – Other Qualifications

License or Certificate

Date of Latest License or Certificate

State or Other Licensing Agency

1f.      

     

     

2f.      

     

     

Section G – Other Qualifications Offer-related training courses (give title and year). Offer-related skills (other languages, computer software/hardware, tools, machinery, typing speed, etc.). Offer-related honors, awards, and special accomplishments (publications, memberships in professional/honor societies, leadership activities, public speaking, and performance awards). Give dates, but do not send documents unless requested.

     

Section H - General

1a. Are you a U.S. citizen? Yes No 1b. If no, give the Country of your citizenship      

1c. Are you a lawful permanent resident of the U.S. (Green Card Holder)? ___Yes ___ No

2. Check this box if you are an adult male born on or after January 1st 1960, and you registered for Selective Service between the ages of 18 through 25 or have an exemption 

3. Were you ever a Federal civilian employee? Yes No  If yes, list highest civilian grade for the following:

3a. Series      

3b. Grade      

3c. From (mm/yyyy)      

3d. To (mm/yyyy)      

Section I – Offeror Certification

I certify that, to the best of my knowledge and belief, all of the information on and attached to this offer is true, correct, complete, and made in good faith. I understand that false or fraudulent information on or attached to this offer may be grounds for not awarding me the contract or for early contract termination after award, and may be punishable by fine or imprisonment. I understand that any information I give may be investigated.

1a. Signature

1b. Date (mm/dd/yyyy)      

Privacy Act Statement

Authority: Foreign Assistance Act, Pub. L. 87-165, as amended; 48 CFR 37.104, Personal services contracts; 48 CFR Ch. 7, App. D, Direct USAID Contracts with a U.S. Citizen or a U.S. Resident Alien for Personal Services.

Purpose: This form collects personal information on offerors for USAID personal services contracts and is used to evaluate your qualifications for award of such a contract. This form is only valid with an OMB Number displayed in accordance with 44 USC 3506(c)(1)(B)(iii)(V).

Routine Uses: The personal information is used to examine and evaluate your qualifications for award of a specific personal services contract. The personal information is also used to determine the most appropriate offeror for such an award. The information may be shared outside of USAID to confirm your qualifications.

Disclosure: Providing personal information is voluntary. However, failure to provide any of the requested information may delay or prevent action on your offer for award of a personal services contract.

Public Burden Statement

We estimate the public reporting burden for this collection is estimated to average sixty (60) minutes per response, including time for reviewing instructions, searching existing data sources, gathering data and completing and reviewing the information. Send comments regarding the burden statement or any other aspect of the collection of information, including suggestions for reducing this burden via e-mail to [email protected]. Do not send offeror forms to this e-mail address; offerors must follow the instructions provided in the solicitation for this contract opportunity.

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